24 - Blue Toe Syndrome Case Study Flashcards Preview

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What is blue toe syndrome?

Blue toe syndrome is a situation of atherothrombotic microembolism causing transient focal ischemia, occasionally with minor apparent tissue loss, but without diffuse forefoot ischemia

The sudden development of a cyanotic digit or lesion of the feet may be the result of atheroembolic decrease or a numer of medical conditions


What are the common symptoms of blue toe syndrome?

- Myalgia and muscle tenderness
- Cutaneous lesions (ulcers and necrosis)
- Lacelike pattern of blue0red mottling with normal skin
- Palpable purpura
- Temperature changes
- Cyanosis
- Absent capillary fill time (CFT)


What is intermittent claudication (a common symptom)

Intermittent claudication - when the patient can walk about a half mile or so before they begin to feel pain in their legs or their legs feel tired

Claudication = cramping in leg due to atherosclerosis during exercise


What are the different clinical tests you can do to confirm whether or not a patient has blue toe syndrome?

Non-invasive vascular evaluation
Plethysmography (detects changes in blood volume)
Doppler ultrasound
Transcutaneous oxygen
Invasive diagnostic studies (arteriogram)


What are three non-invasive vascular tests that you can do?

ABI (ankle/brachial index)
PVR (pulse volume recording)
Toe blood pressures


What is an ABI test?

A quick non-invasive way to check your risk for peripheral artery disease (PAD)

ABI compares your blood pressure measured at your ankle with your blood pressure measured at your arm


How do you interpret an ABI test?

A low ABI number can indivate narrowing or blockage of the arteris in your legs, increasing your risk of circulatory problems and possibly causing heart disease or stroke

Ankle pressure / brachial pressure
(low) / (high) = a small number


What is a PVR?

A PVR study is a non-invasive vascular test in which blood pressure cuffs and a hand-held doppler are used to obtain information about arterial blood flow in the arms and legs


What are toe blood pressures?

Digital cuffs are used to measure the blood pressure on the toes to determine the level or risk the patient is at for blue toe syndrome


How do you interpret toe blood pressures?

- Low risk = above 0.6
- Moderate risk = above 0.4
- High risk = above 0.2
- Severe risk = below 0.2


What is plethysmography?

Measuring and recording changes in volume over a short period of time

A plethysmograph is an instrument for measuring changes in volume within an organ or whole body (usually resulting from fluctuations in the amount of blood or air it contains)


How do you read a plethysmograph?

It looks like squigly lines kind of like an ECG… You read the waveform and tetermine the level of obstruction in the bloodflow you are evaluating


What does a normal plethsymography waveform look like?

"Mountainous form"
Steep upslope
Sharp peak
Distinct dicrotic notch


What does a mild obstruction look like on a plethsymography?

Less of a steep upslope
Less of a distinct peak
Loss of a dicrotic notch (one peak, not two)


What does a moderate obstruction look like on a plethysmography?

"Delayed upslope
Rounded peak
Loss of a dicrotic notch "


What does a severe obstruction look like on a plethysmography?

Delayed upslope
Rounded peak
Very low peak height (barely a wave)


What is another way to detect blood flow?

Doppler ultrasound waveforms


Describe what a normal doppler ultrasound waveform looks like

TRIPHASIC (three little humps in a row)
Bidirectional (goes up then down)
Rapid upstroke/downstroke
Flow reversal
Arterial wall reboud


Describe what a mild obstruction looks like on a doppler ultrasound

BIPHASIC (a little down hump then a big up hump)
Bidirectional (goes up then down)
Decreased peak height
Partial loss of flow reversal
Loss of arterial rebound


Describe what a moderate obstruction looks like on a doppler ultrasound

MONOPHASIC (one little hump)
Rounding of upstroke/downstroke
Decreased peak height
Absend flow reversal
Absent elastic rebound


Describe what a severe obstruction looks like on a doppler ultrasound

Loss of peak height
A sent flow reversal
Absent elastic rebound


What is a trans-cutaneous oxygen test?

A transcutaneous oxygen measurement assesses the oxygen level of SOFT TISSUE - this means it determines the amount of soft tissue perfusion


How does a trans-cutaneous oxygen test determine level of oxygen perfusion?

Measures partial oxygen tension on the skin surface

The temperature of the partial pressure of oxygen is equivalent to the arterial partial pressure of oxygen… PO2 = 45 degrees Celsius

This means that if the temperature detected is 30 degrees or lower, they have a low potential of healing any trauma or wound in that tissue


What is an invasive diagnostic study?



What can arteriograms reveal?

Arteriograms can reveal significant atheromatous change in the arteries


What are some different treatment options if you find an atherosclerotic narrowing of an artery?

Many different treatments can be implemented, so it is important to work them up appropriately and apply the necessary treatment, so you will need to consult vascular

Subintimally dissect it
Balloon it
Stent it
Remove it
Freeze it
Lace it
Excise it


What are all the categories of blue toe syndrome etiology?

- Atheroembolism
- Cardiac embolism
- Hyperviscosity syndromes
- Hypercoagulability states
- Vasculitis
- Miscellaneous


What are the most common etiologies of blue toe syndrome

- #1 = atrial fibrillation (cardiac embolism)
- Leukemias (hyperviscosity syndrome)
- Macroglobulinemia (hyperviscosity syndrome)
- DVT (hypercoagulability state)


What will be on your differential diagnosis for blue toe syndrome?

- Raynaud's phenomenon
- Chilblains
- Acrocyaosis
- Reflex sympathetic dystrophy
- Monkeberg's sclerosis"


What is Raynaud's phenomenon?


Someone may have "transient" vasculitis where they have symptoms for only a couple minutes to an hour, but no long term changes occur