The Vascular Exam Jason Davis, MD

Before the Exam… Obtain history Acute vs. Chronic symptoms Distribution of symptoms Level(s) of extremity pain, etc. Aggravating, Relieving factors Activity/rest, elevation/dependence Co-morbid conditions, vitals

Basic Anatomy to Know

Basic Anatomy to Know

Basic Anatomy to Know

Elements of Vascular Exam Inspect, Palpate, Auscultate Skin pallor/rubor, mottling/ cyanosis, temperature, atrophy, hair distribution Motor function and sensory exam Tissue loss, ulcerations Pulse +/- doppler exam Always compare each w/ contralateral

Elements of Vascular Exam

Vascular Exam tips Doppler signals are NOT Pulses Palpable pulses include carotid, brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, posterior tib Bruits vs. Thrills: Audible vs. Palpable Characterization of Pulses Character (bounding, thready), Rate, Rhythm Characterization of Doppler Signals Triphasic, Biphasic, Monophasic

Trauma / Hypovolemia If you can palpate: Radial pulse, then SBP is >70 - 80 Femoral + Carotid, then SBP >50 - 70 Carotid only, then SBP >40 - 60 NEVER rely on pulses alone for hypovolemia assessment

Lower Extremity Ulcers Arterial (PAD) Distal (often at toes), painful, pale granulation, Assoc w/ atrophy, hairless/shiny skin, rubor-pallor Venous (VI) Lower third, medial malleolus, elevation relieves Assoc w/ edema, larger, irregular, moist base Diabetic Pressure offloading, footwear, self-checks

Common Vascular Problems Peripheral arterial disease Thrombotic (DM, atherosclerosis) Embolic (atrial fibrillation, Aneurysms) Venous insufficiency DVT, thrombophlebitis Carotid artery stenosis Compartment Syndrome Trauma

Compartment Syndrome Leg compartments 6 P’s indicating ischemia Pain Lower: Anterior, Lateral, Superficial & Deep Posterior Upper: Anterior (extensor), Medial (adducter), Posterior (sciatic n.) 6 P’s indicating ischemia Pain Paresthesias Palor Pulselessness Poikilothermia Paralysis

Clinical Scenario #1 Routine 5pm ED consult for cellulitis.

Clinical Scenario #1 Routine 5pm ED consult for cellulitis. You see before leaving within your hrs On arrival, 78yo male w/ DM, CAD, +tobacco Also, hx of “irregular HR” with INR of 1.1 Rt foot cooler than Lt, no palp Rt DP or PT Acute onset severe pain started 3hrs ago Embolectomy and anticoagulation Don’t forget fasciotomy

Clinical Scenario #2 New consult for non-healing ulcer, evaluate for peripheral arterial bypass.

Clinical Scenario #2 New consult for non-healing ulcer, evaluate for peripheral arterial bypass. Obese 63yo M dialysis w/ DM, HTN Legs down in chair, severely edematous Advised to elevate and compression garments, but does not b/c uncomfortable Non-tender medial malleolar ulcer x3 wk B/L DP and PT are palpable

Clinical Scenario #3 Stat consult to 3A for r/o compartment sx. 39yo F s/p cardiac cath via L radial artery Cath performed for cough, was normal After sheath removed, arm doubled in size Nurses want to know when pt going to OR

Clinical Scenario #3 Direct pressure applied, bleeding ceased Stat consult to 3A for r/o compartment sx. 39yo F s/p cardiac cath via L radial artery Cath performed for sneezing, found normal After sheath removed, arm doubled in size Direct pressure applied, bleeding ceased Palpable distal pulses were appreciated Neurovascular exam intact w/ serial exams Arm elevated to facilitate venous return

Berger’s Pet Peaves No overnight pre-op IVF unless dehydration established or elderly pt AND afternoon case Reglan for N/V unless obstruction, espec DM Zofran ONLY if nausea refractory to Reglan Only attg name on consents except as witness Residents can, however, sign blood consents SCD’s for AAA’s only (NOT CEA’s, bypasses, etc) Vaseline gauze, NEVER iodoform gauze Do NOT elevate extremities after access cases Increases steal symptoms and neuropathy Peri-op edema will resolve, heart level adequate Dextran x24hrs for all CEA’s EXCEPT Berger’s

Vascular Studies Duplex Doppler B-mode doppler ABI/PVR (LEADs)