1. A Palliative Approach to Peripheral Vascular Disease/ Gangrene
Connie Sarvis
RN, BN, MN, CON(c),IIWCC, CWS, FCCWS
Skin and Wound Consultant
Seven Oaks General Hospital

2. Peripheral Vascular Disease
PAD OR PVD ?
12-15% OF ADULTS OVER 50
(THOSE SEEKING HELP)
PAIN OR INFECTION

3. Prognosis Symptoms remain stable in about 15/20 cases
Symptoms gradually become worse in 4/20 cases
Symptoms deteriorate severely in 1/20 cases

4. RISK FACTORS
Advanced Age
Smoking
Diabetes

5. Other Risk Factors Obesity Sedentary Lifestyle Stress
Heredity
Diet
Hypertension
Hyperlipidemia
Elevated Blood Glucose
Cardiovascular Disease
Cerebrovascular Disease

6. CAUSES OF PVD
ATHEROSCLEROSIS
INJURY
INFECTION

8. Signs and Symptoms

9. Symptoms Claudication
Pt feels cramping or pain in the back of the calf when walking
As PVD continues to progress, claudication/cramping in the calves occurs even when at rest

10. Other Pain
If the femoral artery is blocked , then pain may extend up to the thighs and buttocks when walking

11. Other Signs and Symptoms
Loss of hair growth on entire leg or in patches
Absent pedal pulses (later stage)
Rubor (later)
Elevation Pallor (Later)
Cool Feet
Delayed capillary refill

12. ABI’s
Measures
Vascular
Perfusion
Doppler Assessment

13. 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

14. How Do You Get the Number?
Formula (ABI)
Ankle Pressure
Brachial Pressure

15. 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

16. Why Might Toe Pressure Numbers Differ?
Microcirculation vs Macrocirculation!

17. 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

18. BUT….
How do we differentiate between ulcers that will heal and those that need palliative care?

19. Characteristic
Arterial
Venous
Location
Usually distal
(Top of foot)
Above malleolus
Size
Small/punched out
Can be quite large
Shape/Margins
Round/Smooth
Irregular
Depth
Can become quite deep
Usually shallow
Wound Bed Base
Pale pink – grey
Variable – usually beefy red
Surrounding Skin
Pale
Pigmented

20. What happens to an Arterial Wound?

21. Remember!
SKIN IS THE TISSUE MOST RESISTANT TO ISCHEMIA AND SO IS USUALLY THE LAST TO UNDERGO NECROSIS!!

22. Often times the vascular status is discovered only when trauma occurs and there is not enough vascular perfusion to heal the wound

23. TREATMENT Depends upon patient’s condition
Only curative treatment is surgical intervention
Otherwise medical management is preferable

24. Surgical Procedures Femoral Popliteal Bypass Angioplasty
Plaque excision
Stent

25. OF COURSE SURGERY MAY HAVE ITS’ DRAWBACKS TOO!!

26. Remember! IF SURGERY IS UNDERTAKEN – THERE IS A FRESH BLOOD SUPPLY FOR ANY RESIDENT BACTERIA! = INFECTION!!

27. Conservative Treatment Cadexomer Iodine and Povidine

28. Low Dose ASA to prevent clots
Other Measures?
Viagara??
Low Dose ASA to prevent clots
Statin Medication to lower plaque buildup

29. GANGRENE decay of body tissues caused by infection/ischemia/thrombus
can be black, brown or green
Malodorous!!
Generally associated with Diabetics and Smoking
Frostbite

30. BEGINS AT DISTAL PART OF LIMB DUE TO ISCHEMIA
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

31. DRY GANGRENE

32. 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.

34. BUERGER’S DISEASE

35. LOCAL WOUND CARE Keep wound Dry
Do NOT cleanse with saline first (gangrene)
Do not use Eusol, Saline soaks or Hydrogen Peroxide, Gel’s.

36. Other Comfort Tips Avoid tight footwear/binding clothing/dressings
Hang foot down (at night)
Encourage smoking cessation
Avoid trauma

37. Fentanyl pre-dressing change Systemic pain relievers
Gapapentin
Morphine/gel?

38. Infection
Keep gangrenous/arterial area as dry as possible
Patients very prone to developing osteomyelitis as ulcers can be quite deep
Povidine – Don’t dress until dry
Tightly woven dressings better (no loose fibres)

39. GOAL
Prevent Pain!
Prevent Infection!
Prevent Amputation!

40. Questions?