1. The Vascular Exam
Jason Davis, MD

2. 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

3. Basic Anatomy to Know

4. Basic Anatomy to Know

5. Basic Anatomy to Know

6. 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

7. Elements of Vascular Exam

8. 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

9. Trauma / Hypovolemia If you can palpate:
Radial pulse, then SBP is >
Femoral + Carotid, then SBP >
Carotid only, then SBP >
NEVER rely on pulses alone for hypovolemia assessment

10. 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

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

12. 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

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

14. 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

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

16. 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

17. 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

18. 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

19. 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

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