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finals > vascular > Flashcards

vascular Flashcards

1
Q

types of skin ulcers

A

venous
arterial
diabetic foot
pressure

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2
Q

why do you get arterial ulcers

A

insufficient BS to the skin due to PAD

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3
Q

why do you get venous ulcers

A

pooling of blood + waste products in the skin secondary to venous insufficiency

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4
Q

Waterlow Score

A

risk assessment tool for estimating an individual patient’s risk of developing a pressure ulcer

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5
Q

typical arterial ulcers

A

occur distally (toes/foot dorsum)
PAD - absent pulses, pallor, intermittent claudication
smaller
deeper
well defined borders
punched out appearance
pale colour due to poor BS
less likely to bleed
painful
pain worse at night (lying down)
pain worse on elevating + improved by lowing leg (as gravity helps circulation)

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6
Q

typically venous ulcers

A

occur in gaiter area (top of foot + bottom of calf muscle)
chronic venous changes - hyperpigmentation, venous eczema, lipodermatosclerosis
often occur after minor leg injury
larger
more superficial
irreg, gently sloping border
more likely to bleed
less painful
pain relieved by elevation + worse on lowering leg

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7
Q

ix for arterial + venous ulcers

A

Ankle-brachial pressure index (ABPI) - to assess poor arterial flow
blood tests - FBC, CRP, co-morbidities
charcoal swabs if infection suspected
skin biopsy if skin cancer suspected - +2 wk wait

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8
Q

mx arterial ulcers

A

urgent referral to vascular to consider surgical revascularisation

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9
Q

referral for venous ulcers

A

refer to:
vascular surgery is suspect mixed venous + arterial
tissue viability / specialist leg ulcer clinic if complex or non-healing
derm if skin cancer
pain clinics
diabetic ulcer services

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10
Q

tx venous ulcers

A

input from district nurses or tissue viability nurses

cleaning wound, debridement, dressing

COMPRESSION BANDAGING therapy
(stockings are for after they have healed)

pentoxifylline to improve healing (peripheral vasodilator)

abx if infect
analgesia (avoid NSAIDs)

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11
Q

neuropathic ulcer presentation

A

tingling and numbness over area
on bony prominences + peripheries
deep, calloused + punched out
in poorly controlled diabetic px

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12
Q

Venous thromboembolism (VTE)

A

blood clot developing in the circulation, secondary to blood stagnation or hypercoagulable states. When a thrombus develops in a deep vein, it is called a deep vein thrombosis (DVT).

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13
Q

RFs VTE

A

Immobility
Recent surgery
Long haul travel
Pregnancy
Hormone therapy with oestrogen
Malignancy
Polycythaemia
Systemic lupus erythematosus
Thrombophilia

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14
Q

examples of thrombophilias

A

conditions that predispose patients to develop blood clot

Antiphospholipid syndrome !!
Factor V Leiden
Antithrombin deficiency
Protein C or S deficiency
Hyperhomocysteinaemia
Prothombin gene variant
Activated protein C resistance

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15
Q

VTE prophylaxis

A

LMWH - enoxaparin
unless CI (active bleeding/existing anticoag)
Anti-embolic compression stockings are also used (CI in PAD)

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16
Q

presentation DVT

A

unilateral :
Calf or leg swelling
- the calf circumference is measured 10cm below the tibial tuberosity. >3cm is significant.
Dilated superficial veins
Tenderness to the calf (particularly over the site of the deep veins)
Oedema
Colour changes to the leg

Consider a pulmonary embolism (e.g., shortness of breath and chest pain)

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17
Q

dx DVT

A

Wells score, if:
Likely: perform a leg vein ultrasound
Unlikely: perform a d-dimer, and if positive, perform a leg vein ultrasound

Repeat -ve US scans after 6-8 days if the px has a +ve D-dimer and the Wells score suggests a DVT is likely.

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18
Q

conditions that can cause raised d-dimer

A

Pneumonia
Malignancy
Heart failure
Surgery
Pregnancy

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19
Q

mx DVT

A

apixaban or rivaroxaban is the initial anticoagulant
LMWH is main alternative

started asap is suspected + delay in scanning

consider catheter-directed thrombolysis in patients with a symptomatic iliofemoral DVT

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20
Q

long term anticoags DVT

A

DOAC, warfarin or LMWH.

3 months with a reversible cause (then review)
3-6 months in active cancer (then review)
Long-term for unprovoked VTE, recurrent VTE or an irreversible underlying cause (e.g., thrombophilia)

Inferior vena cava filter if already on anticoag / unsuitable for it

21
Q

features of acute limb ischaemia

A

Pain
Pallor
Pulseless
Paralysis
Paraesthesia
Perishing cold

22
Q

initial ix for acute limb-threatening ischaemia

A

handheld arterial Doppler examination

If Doppler signals are present, an ankle-brachial pressure index (ABI) should also be obtained

23
Q

what is peripheral arterial disease (PAD)

A

narrowing of the arteries supplying the limbs and periphery, reducing the BS

usually refers to the lower limbs -> sx of claudication

24
Q

what is intermittent claudication

A

sx of ischaemia in a limb occurring during exertion and relieved by rest

crampy achy pain in the calf, thigh or buttock muscles associated with muscle fatigue when walking beyond a certain intensity.

25
Q

what is critical limb ischaemia

A

end-stage of peripheral arterial disease, where there is an inadequate supply of blood to a limb to allow it to function normally at rest = signif risk of losing limb

26
Q

critical limb ischaemia features

A

pain at rest - worse at night when the leg is raised, as gravity no longer helps pull blood into the foot
non-healing ulcers
gangrene

27
Q

what is acute limb ischaemia

A

rapid onset of ischaemia in a limb
-due to a thrombus blocking the arterial supply of a distal limb

28
Q

what is gangrene

A

death of the tissue, specifically due to an inadequate blood supply

29
Q

what is atherosclerosis

A

affects the medium and large arteries

caused by chronic inflammation + activation of the immune system in the artery wall

Lipids are deposited in the artery wall -> dev of fibrous atheromatous plaques
- stiffening -> HTN + heart strain
- stenosis -> reduced BF
- plaque rupture -> thrombus

30
Q

Non-modifiable risk factors atherosclerosis

A

Older age
Family history
Male

31
Q

modifiable risk factors atherosclerosis

A

Smoking
Alcohol consumption
Poor diet (high in sugar and trans-fat and low in fruit, vegetables and omega 3s)
Low exercise / sedentary lifestyle
Obesity
Poor sleep
Stress

32
Q

Medical Co-Morbidities increasing atherosclerosis risk

A

Diabetes
Hypertension
Chronic kidney disease
Inflammatory conditions such as rheumatoid arthritis
Atypical antipsychotic medications

33
Q

end results of atherosclerosis

A

Angina
Myocardial infarction
Transient ischaemic attack
Stroke
Peripheral arterial disease
Chronic mesenteric ischaemia

34
Q

what is leriche syndrome

A

Occlusion in the distal aorta or proximal common iliac artery

35
Q

triad of leriche syndrome

A

Thigh/buttock claudication
Absent femoral pulses
Male impotence

36
Q

signs of CVD

A

RFs:
Tar staining on the fingers
Xanthomata (yellow cholesterol deposits on the skin)
Signs:
Missing limbs or digits after previous amputations
Midline sternotomy scar (previous CABG)
A scar on the inner calf for saphenous vein harvesting (previous CABG)
Focal weakness suggestive of a previous stroke

37
Q

signs of arterial disease

A

Skin pallor
Cyanosis
Dependent rubor (a deep red colour when the limb is lower than the rest of the body)
Muscle wasting
Hair loss
Ulcers
Poor wound healing
Gangrene (breakdown of skin and a dark red/black change in colouration)

38
Q

what is buerger’s test

A

used to assess for peripheral arterial disease in the leg
- px supine, raise feet to 45º for 1-2 minutes
- pallor? - which angle
- hang legs down again - blue -> dark red?

39
Q

mx intermittent Claudication

A

lifestyle changes
exercise training

medical
- Atorvastatin 80mg
- Clopidogrel 75mg OD (aspirin if clop unsuitable)
- Naftidrofuryl oxalate (5-HT2 receptor antagonist that acts as a peripheral vasodilator)

surgical
- Endovascular angioplasty and stenting
- Endarterectomy – cutting the vessel open and removing the atheromatous plaque
- Bypass surgery – using a graft to bypass the blockage

40
Q

Mx of Critical Limb Ischaemia

A

urgent referral to the vascular team
analgesia

Urgent revascularisation can be achieved by:
Endovascular angioplasty and stenting
Endarterectomy
Bypass surgery
Amputation of the limb if it is not possible to restore the blood supply

41
Q

mx acute limb ischaemia

A

urgent referral to vascular team

42
Q

what is chronic venous insufficiency

A

occurs when blood does not efficiently drain from the legs back to the heart

Usually a result of damage to the valves inside the veins

The damage may occur with age, immobility, obesity, prolonged standing or after a DVT

Often associated with varicose vein

43
Q

what is venous hypertension

A

occurs when the pressure inside the veins in the lower extremities increases due to weakened vein valves
blood pools in veins of legs

44
Q

where are venous ulcers most common

A

gaiter area - below the knee and above the ankle

45
Q

what is venous eczema

A

dry, itchy, flaky, scaly, red, cracked skin caused by a chronic inflammatory response

46
Q

what is lipodermatosclerosis

A

hardening and tightening of the skin and tissue beneath the skin
- i.e. subcutaneous fibrosis = panniculitis
->“inverted champagne bottle” appearance

47
Q

what is atrophie blanche

A

patches of smooth, porcelain-white scar tissue on the skin, often surrounded by hyperpigmentation

48
Q

risks of carotid endarterectomy

A

(incision in the neck, opening the carotid artery and scraping out the plaque)
stroke (around 2%)
injury of nearby nerves:
- Facial nerve injury causes facial weakness
- Glossopharyngeal nerve injury causes swallowing difficulties
- Recurrent laryngeal nerve (a branch of the vagus nerve) injury causes a hoarse voice
- Hypoglossal nerve injury causes unilateral tongue paralysis

49
Q

what is virchow’s triad

A

blood stasis
hyper-coagulability
endothelial damage/ vessel wall injury

finals (27 decks)

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