How is it Measured? Blood Pressure (Systolic only taken on both arms Blood Pressure (Systolic only taken on both ankles Doppler is used (8 mgHz) Arm – Brachial pulse is used Legs – Dorsalis Pedis is used
How Do You Get the Number? Formula (ABI) Ankle Pressure Brachial Pressure
But what do the numbers Mean? Result of <0.5 = Ischemia Result of 0.5 – 0.8 = Moderate Ischemia Result of 0.8 – 1.0 = Mild Ischemia/Normal Anything over 1.0 is either normal or may indicate calcified arteries in Diabetics. In this case toe pressures are indicated
Why Might Toe Pressure Numbers Differ? Microcirculation vs Macrocirculation!
Results 55 mmHg = >0.6 toe brachial index (Low Risk) 40 mmHg = >0.4 toe brachial index (Mod. Risk) 20 mmHg = >0.2 toe brachial index (High Risk) <20 mmHg = < 0.2 toe brachial index (Severe Risk) If trying to heal an ulcer on the heel, then poor vascularization in the toes is not as critical
BUT…. How do we differentiate between ulcers that will heal and those that need palliative care?
CharacteristicArterialVenous LocationUsually distal (Top of foot) Above malleolus SizeSmall/punched out Can be quite large Shape/MarginsRound/SmoothIrregular DepthCan become quite deep Usually shallow Wound Bed BasePale pink – greyVariable – usually beefy red Surrounding Skin PalePigmented
What happens to an Arterial Wound?
Remember! SKIN IS THE TISSUE MOST RESISTANT TO ISCHEMIA AND SO IS USUALLY THE LAST TO UNDERGO NECROSIS!!
Often times the vascular status is discovered only when trauma occurs and there is not enough vascular perfusion to heal the wound
TREATMENT Depends upon patients condition Only curative treatment is surgical intervention Otherwise medical management is preferable
Remember! IF SURGERY IS UNDERTAKEN – THERE IS A FRESH BLOOD SUPPLY FOR ANY RESIDENT BACTERIA! = INFECTION!!
Conservative Treatment Cadexomer Iodine and Povidine
Viagara?? Low Dose ASA to prevent clots Statin Medication to lower plaque buildup Other Measures?
GANGRENE decay of body tissues caused by infection/ischemia/thrombus can be black, brown or green Malodorous!! Generally associated with Diabetics and Smoking Frostbite
DRY GANGRENE BEGINS AT DISTAL PART OF LIMB DUE TO ISCHEMIA OFTEN IN THE TOES OF ELDERLY PEOPLE SPREADS SLOWLY APPEARS BLACK, SHRUNKEN (MUMMIFIED) PT. HAS DULL ACHE AND SENSATIONS OF COLDNESS IF CAUGHT EARLY AND REVASCULARIZED – SOMETIMES THE LIMB/DIGIT CAN BE SALVAGED
WET GANGRENE Generally occurs in moist tissue and organs Tissue is infected by bacteria which have a putrid smell to them Develops quickly due to arterial and/or venous blockage Toxic products of bacteria responsible for sepsis – death.
LOCAL WOUND CARE Keep wound Dry Do NOT cleanse with saline first (gangrene) Do not use Eusol, Saline soaks or Hydrogen Peroxide, Gels.
Other Comfort Tips Avoid tight footwear/binding clothing/dressings Hang foot down (at night) Encourage smoking cessation Avoid trauma
Infection Keep gangrenous/arterial area as dry as possible Patients very prone to developing osteomyelitis as ulcers can be quite deep Povidine – Dont dress until dry Tightly woven dressings better (no loose fibres)