Peripheral Vascular Examination PDF

Peripheral Vascular Examination  General inspection Clinical signs Missing limbs/digits: may be due to amputation secondary to critical ischaemia. Scars: may indicate previous surgical procedures (e.g. bypass surgery) or healed ulcers. ...

Peripheral Vascular Examination  General inspection Clinical signs Missing limbs/digits: may be due to amputation secondary to critical ischaemia. Scars: may indicate previous surgical procedures (e.g. bypass surgery) or healed ulcers.  Objects and equipment Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current clinical status: Medical equipment: note any dressings and limb prosthesis. Mobility aids: items such as wheelchairs and walking aids give an indication of the patient’s current mobility status. Vital signs: charts on which vital signs are recorded will give an indication of the patient’s current clinical status and how their physiological parameters have changed over time. Prescriptions: prescribing charts or personal prescriptions can provide useful information about the patient’s recent medications.  Upper limbs Inspect and compare the upper limbs. Peripheral cyanosis - bluish discolouration of the skin associated with low SpO2 in the affected tissues (e.g., may be present in the peripheries in PVD due to poor perfusion).  Upper limbs Peripheral pallor - a pale colour of the skin that can suggest poor perfusion (e.g., PVD).  Upper limbs Tar staining - caused by smoking, a significant risk factor for cardiovascular disease (e.g., PVD, coronary artery disease, hypertension).  Upper limbs Xanthomata - raised yellow cholesterol-rich deposits that are often noted on the palm, tendons of the wrist and elbow. Xanthomata are associated with hyperlipidaemia - another important risk factor for cardiovascular disease.  Upper limbs Gangrene - tissue necrosis secondary to inadequate perfusion. Typical appearances include a change in skin colour (e.g., red, black) and breakdown of the associated tissue.  Temperature and capillary refill time (CRT) Temperature Place the dorsal aspect of the hands onto the patient’s upper limbs to assess temperature: In healthy individuals, the upper limbs should be symmetrically warm, suggesting adequate perfusion. A cool and pale limb is indicative of poor arterial perfusion.  Temperature and capillary refill time (CRT) Capillary refill time (CRT) Measuring capillary refill time (CRT) in the hands is a useful way of assessing peripheral perfusion: Apply five seconds of pressure to the distal phalanx of one of a patient’s fingers and then release. In healthy individuals, the initial pallor of the area we compressed should return to its normal colour in less than two seconds. A CRT that is greater than two seconds suggests poor peripheral perfusion. Prior to assessing CRT, check that the patient does not currently have pain in their fingers.  Character of Pulse Important characteristics of pulses to consider include: Rate: The rate of the pulse is the number of times the artery expands and contracts in one minute. This is also known as the heart rate, and is typically measured in beats per minute (bpm). A normal heart rate for an adult is between 60-90 bpm. A heart rate that is too fast or too slow can indicate a problem with the heart or cardiovascular system. Rhythm: The rhythm of the pulse is the pattern of expansion and contraction. A regular rhythm is when the pulses are evenly spaced and of equal strength. An irregular rhythm can indicate a problem with the heart’s electrical system, such as atrial fibrillation.  Character of Pulse Volume: The volume of the pulse refers to the strength of the expansion and contraction. A strong pulse indicates good blood flow, while a weak pulse can indicate poor blood flow or a decrease in cardiac output. Character: The character of the pulse refers to the shape of the expansion and contraction pressure waves. A regular character indicates that the pulse is consistent in shape and duration. An irregular character can indicate a problem with the heart’s structure or function.  Pathological pulse characters Waterhammer/Large volume pulse A waterhammer pulse has a sharper upstroke and increased amplitude. It is typically caused by aortic regurgitation. Slow-rising/Anacrotic pulse A slow-rising pulse has, as the name suggests, a slower upstroke and reduce amplitude. It is typically caused by aortic stenosis.  Pathological pulse characters Pulsus bisfiriens Pulsus bisfiriens has a character of two narrowly separated peaks during systole. It is caused by mixed aortic stenosis with aortic regurgitation valve disease. Pulsus alternans Pulsus alternans develops in left ventricular systolic impairment. The pulse alternates between low and high volume; a low ejection fraction produces the low volume pulse, which leads to ventricular filling and a stronger contraction in the subsequent pulse. Double impulse apex beat When palpating the apex beat, a feeling of 2 beats within a single systole is suggestive of hypertrophic obstructive cardiomyopathy (HOCM).  Pathological pulse characters Pulsus paradoxus Normally during inspiration, systolic arterial blood pressure can decrease as much as 10 mm Hg, and pulse rate increases to compensate. Causes: Cardiac tamponade (commonly) Constrictive pericarditis Restrictive cardiomyopathy Chronic obstructive pulmonary disease (occasionally) Severe asthma Severe pulmonary embolism Hypovolemic shock (rarely)  Absent radial pulse Occasionally, a radial pulse may be completely absent and cannot be palpated or found on ultrasound. Causes include: Iatrogenic, e.g. post-catheterization Congenital absence Aortic dissection involving the subclavian artery Peripheral artery embolism Compression by cervical rib Takayasu’s arteritis A visual representation of normal and pathological pulses  Pulses Radial pulse Palpate the patient’s radial pulse, located at the radial side of the wrist, with the tips of the index, middle and ring fingers aligned longitudinally over the course of the artery. Once we have located the radial pulse, we should assess the rate and rhythm.  Pulses Radio-radial delay Radio-radial delay describes a loss of synchronicity between the radial pulse on each arm. To assess for radio-radial delay: Palpate both radial pulses simultaneously. In healthy individuals, the pulses should occur at the same time. If the radial pulses are out of sync, this would be described as radio-radial delay. Causes of radio-radial delay include: Subclavian artery stenosis (e.g., compression by a cervical rib) Aortic dissection  Pulses Blood pressure (BP) Measure the patient’s blood pressure in both arms. Wide pulse pressure (more than 100 mmHg of difference between systolic and diastolic blood pressure) can be associated with aortic regurgitation and aortic dissection, or in athlets.  Lower limbs Inspection Peripheral pallor - a pale colour of the skin that can suggest poor perfusion.  Lower limbs Ispection Peripheral cyanosis - bluish discolouration of the skin associated with low SpO2 in the affected tissues. Ischemic rubour - a dusky- red discolouration of the leg that typically develops when the limb is dependent. Ischaemic rubour occurs due to the loss of capillary tone associated with PVD.  Lower limbs Ispection Venous ulcers - typically large and shallow ulcers with irregular borders that are mildly painful. These ulcers most commonly develop over the medial aspect of the ankle. Arterial ulcers - typically small, well-defined, deep ulcers that are very painful. These ulcers most commonly develop in the  Lower limbs Ispection Gangrene - tissue necrosis secondary to inadequate perfusion. Typical appearances include a change in skin colour (e.g., red, black) and breakdown of the associated tissue.  Lower limbs Inpection Missing limbs, toes, fingers: due to amputation secondary to critical ischaemia. Scars: may indicate previous surgical procedures (e.g., bypass surgery) or healed ulcers. Hair loss: associated with PVD due to chronic impairment of tissue perfusion. Muscle wasting: associated with chronic peripheral vascular disease. Xanthomata: raised yellow cholesterol- rich deposits that may be present over the knee or ankle, associated with hyperlipidaemia Paralysis: critical limb ischaemia can cause weakness and paralysis of a limb.  Lower limbs Temperature and capillary refill time (CRT) Temperature Place the dorsal aspect of the hands onto the patient’s lower limbs to assess and compare temperature: In healthy individuals, the lower limbs should be symmetrically warm, suggesting adequate perfusion. A cool and pale limb is indicative of poor arterial perfusion.  Lower limbs Capillary refill time (CRT) Measuring capillary refill time (CRT) in the lower limbs is a useful screening tool to quickly assess peripheral perfusion: Apply five seconds of pressure to the distal phalanx of one of a patient’s toes and then release. In healthy individuals, the initial pallor of the area you compressed should return to its normal colour in less than two seconds. A CRT that is greater than two seconds suggests poor peripheral perfusion. Prior to assessing CRT, we should check that the patient does not currently have pain in their toes.  Pulses Femoral pulse Palpation of the femoral pulse: The femoral pulse can be palpated at the mid- inguinal point, which is located halfway between the anterior superior iliac spine and the pubic symphysis.  Pulses Femoral pulse Assess for radio-femoral delay: Palpate the femoral pulse and radial pulse simultaneously. In healthy individuals, the pulses should occur at the same time. If the pulses are out of sync, this indicates radio-femoral delay. Auscultate over the femoral pulse to screen for bruits: Bruits in this region suggest either femoral or iliac stenosis.  Pulses Popliteal pulse Palpate the popliteal pulse: The popliteal pulse can be palpated in the inferior region of the popliteal fossa. With the patient supine, ask them to relax their legs and place thumbs on the tibial tuberosity. Passively flex the patient’s knee to 30º as you curl your fingers into the popliteal fossa. This should allow you to feel the pulse, as you compress the popliteal artery against the tibia. This pulse is often difficult to palpate. The popliteal artery is one of the deepest structures within the fossa.  Pulses Posterior tibial pulse Palpate the posterior tibial pulse: The posterior tibial pulse can be located posterior to the medial malleolus of the tibia. Palpate the pulse to confirm its presence and then compare pulse strength between the feet. * Dorsalis pedis pulse Palpate the dorsalis pedis pulse: The dorsalis pedis pulse can be located over the dorsum of the foot, lateral to the extensor hallucis longus tendon, over the second and third cuneiform bones. Palpate the pulse to confirm its presence and then compare pulse strength between the feet.  Buerger’s test Buerger’s test is used to assess the adequacy of the arterial supply to the leg. To perform Buerger’s test: 1. With the patient positioned supine, stand at the bottom of the bed and raise both of the patient’s feet to 45º for 1-2 minutes.  Buerger’s test 2. Observe the colour of the limbs: The development of pallor indicates that peripheral arterial pressure is unable to overcome the effects of gravity, resulting in loss of limb perfusion. If a limb develops pallor, note at what angle this occurs (e.g. 25º), this is known as Buerger’s angle. In a healthy individual, the entire leg should remain pink, even at an angle of 90º. A Buerger’s angle of less than 20º indicates severe limb ischaemia.  Further assessments and investigations Suggest further assessments and investigations to the examiner: Blood pressure measurement: to identify significant discrepancies between the two arms suggestive of aortic dissection. Cardiovascular examination: to complete assessment of the vascular system. Ankle-brachial pressure index (ABPI) measurement: to further assess lower limb perfusion. Upper and lower limb neurological examination: if gross neurological deficits were noted during the peripheral vascular examination.  Instrumental methods for examination of arterial perfusion Blood tests. Blood tests are done to check for conditions related to PAD such as high cholesterol, high triglycerides and diabetes. Ultrasound of the legs or feet. This test uses sound waves to see how blood moves through the blood vessels. Doppler ultrasound is a special type of ultrasound used to spot blocked or narrowed arteries. Angiography. This test uses X-rays, magnetic resonance imaging (MRI) scans or computerized tomography (CT) scans to look for blockages in the arteries. Before the images are taken, dye (contrast) is injected into a blood vessel. The dye helps the arteries show up more clearly on the test images.