Vascular wound management

Question 1

Vascular wounds are…

caused by what and result in what

Answer 1

interruption in blood flow in any one or more vessels can cause pathology resulting in

• integumentary changes
• wounds
• impaired healing

can be arterial or venous

Question 2

vascular wounds

causes from arterial system

Answer 2

• peripheral artery disease
• ischemia

Question 3

vascular system

venous system causes

Answer 3

• venous HTN
• chronic venous insufficiency

Question 4

Arterial dysfunction

1. arterial occulsion can occur where?
2. PAD symptoms

Answer 4

arterial occulsion can occur in

• macro-circulation: named arteries
• micro-circulation: arterioles/capillaries <0.5mm (not perfusing correctly)

peripheral arterial disease: symptoms include

• fatigue, heaviness
• claudication
• resting pain - related to positional elevation

Question 5

Describe the phases of ischemia related to PAD

Answer 5

• first critical phase: decreased blood flow; wounds heal more slowly or become infected and dont heal
• second critical phase: exercise/activity cause ischemia and pain
• third critical phase: resting pain, gangrene, non- healing wounds

Question 6

PAD vs lumbar spinal stenosis

Answer 6

• symptoms are similar: pain in calf/thigh
• PAD/ischemia; symptoms will decrease with cessation of activity
• spinal stenosis pain: symptoms will decrease only with change of position; stand to sit or sit to supine

Question 7

Arterial mircosystem

describe

Answer 7

• superficial and deep arterioles, venules, and capillaries present within the dermis, cutaneous branches
• capillary loop allow filtration in the arterial end and absorption in the venous end. each papillae usually contains a capillary loop
• increased pressure at either end, leads to increased interstitial edema or shunting of blood to other areas
• defects in capillary loop mechanism occur in patient with diabetes along with micro sclerosis (hard to test for)

Question 8

Arterial micro dysfunction

clinical signs

Answer 8

• clinical signs are more subtle than macro circulation dysfunction
• re-development of necrotic tissue within 24 hours of debridement

~

Question 9

characterisitics of arterial ulcers

1. Pain
2. location
3. tissue
4. wound edges
5. exudate
6. periwound
7. pulses
8. temp

Answer 9

• pain: can be severe, increased with elevation
• location: distal toes (fingers), dorsal foot, areas of trauma, less frequently, distal tibia, distal ischemia
• tissue: pale granulation (if any), dry, nectoric, slough, gangrene,
• wound edges: punched out lesion
• exudate: none unless infected (dry)
• peri-wound: dry, hairless, thin, skiny skin, loss of hair, dusky or cynanotic
• pulses: decreased or absent
• temperature: decreased

Question 10

mangement of arterial ulcers

Answer 10

• local wound care
• prevent infection (increased risk)
• debride carefully: remember that there is ischemia
• maximize prefusion: avoid noxious stimuli/smoking
• exercise: gait/mobility; aerobic/progressive walking (claudication guidelines)
• surgical revascularization if ABI < 0.4: bypass, percutaneous balloon angioplasty

Question 11

Local wound care

describe parts of local wound care of arterial wounds

Answer 11

• protects surrounding skin: moisturize, avoid adhesives, reduce friction between toes, pad to protect ischemic tissue (so edges can grow)
• wound bed: moisture, debride cautiously, prevent maceration
• maximize circulation: positioning, avoid compression, keep limb warm (prevent further vasoconstriction)
• education: wound etiology, intervention strategies, risk factor modifcation, foot care guidelines

Question 12

Gangrene risk factors

Answer 12

• obesity
• DM
• smoking
• hyperlipidemia
• IV drug use
• surgery
• trauma
• alchololism

Question 13

subtypes of gangrene

dry gangrene

Answer 13

• arterial obstruction following PAD or vasculitis in the lower extremities
• features of black eschar located on the distal extremities: (clear demarcated, hard, dry, foul order, painful)
• skin is atrophic, shiny, free of hair,
• limb is pale cold and pulseless

Question 14

subtypes of gangrene

wet gangrene

Answer 14

• necrotizing soft tissue infection usually caused by bacteria into site of wound
• edematous, moist appearing skin characterized by: cyanosis, blistering, foul odor painful
• patient may also present with systemic signs and symptoms

Question 15

subtypes of gangrene

gas gangrene/fourneir’s gangrene

Answer 15

• severe pain with evidence of gas (crepitus) on palpation
• fourneir’s gangrene: life-threatening necrotiing fasciitis involving the gential or perineal regions

Question 16

Management of dry gangrene

medical?

Answer 16

• risk reduction strategies (smoking cessation, diet, exercise and routine foot exam)
• revascularization
• amputation/debridement once blood flow is optimized

Question 17

management of

wet/gas gangrene

Answer 17

• aggressive surgical debridement
• systemic broad-spectrum antibiotics
• wet: carbapenem + MRSA agent + clindmycin
• gas: clindamycin + piperacillin-tazbactam

Question 18

venous system

Answer 18

• superficial veins: greater and lesser saphenous
• deep veins: paired with each corresponding artery (femoral, popliteal, tibial)
• perforator veins: conduits BTW superficial and deep systems
• communicating veins: connect veins in same systems

damage to any can cause blood to pool typically starts in superficial veins

Question 20

chronic venous insufficiency

how does this cause wounds

Answer 20

• slow healing and recurrence is common
• ulcers from CVI: referred to as venous stasis, venous HTN is root cause
• small trauma to skin leads to open wounds (impaired vascular system)

Question 21

what is venous HTN caused by

Answer 21

• insufficient valves
• from deep communicating or superficial veins
• obstruction of LE veins, ex: pregnancy, obseity, clotting/thrombus
• insufficient calf muscle pump (soleus and gastroc = enough ROM?)
• prolonged standng (esp. no walking)
• neuromuscular/MSK disease of LE
• immobilization of LE

Question 22

Venous HTN

what happens as a result of this

Answer 22

• results in elevated capillary pressure
• leak fluid, molecules, RBC into interstitial space
• leaked RBC release forms hemosiderin in skin

Question 23

Venous dysfunction: CEAP classification system

Answer 23

• Clinical signs: varicose veins, edema, pigmentation, healed or active ulcers
• Etiology: congenital, primary, secondary causes
• Anatomic: superficial, deep, perforator veins
• Pathophysiology: reflux, obstruction, both

Question 24

CEAP classification: clinical signs

Answer 24

C0: no visible or palpable signs of venous disease
C1: telangioctases or reticular veins
C2: varicose veins
C3: edema
C4b: lipodermatosclerosis or atrophie blanche
C5: healed venous ulcer
C6: active venous ulcer

classification

Question 25

CEAP: etiologic

Answer 25

Ec: congential Ep: primary Es: secondary (post thrombotic) En: no venous cause identified

Question 26

CEAP: anatomic

Answer 26

As: superficial veins Ap: perforator veins Ad: deep veins An: no venous location identified

Question 27

CEAP: pathophysiologic

Answer 27

Pr: reflux Po: obstruction Pr,o: refulx and obstruction Pn: no venous pathophyiology identifiable

Question 28

characteristics of venous ulcers ## Footnote 1. Pain 2. location 3. tissue 4. wound edges 5. exudate 6. periwound 7. pulses 8. temp

Answer 28

- pain: mild to moderate, decreased with compression or elevation - location: medial malleolus, medial lower leg, usually lower 3rd of LE - tissue: irregular shape, ruddy wound bed, fibrous yellow or glossy coating over wound bed, varies but may be copious - peri-wound: edema, cellulitis, hemisiderin staining, lipodermatosclerosis - pulses: normal or decreased from edema (hard to find) - temperature: normal to mild warmth

Question 29

Management of venous ulcer

Answer 29

- **local wound care**: similar to other chronic wounds; absorptive dressing, control bacteria, protect peri-ound skin with barrier for skin, moisturize dry scaly skin - **compression therapy**: start low and gradually increase elevation to enhance venous return; assess to be sure no PAD - **ablation of saphenous vein**: reduce recurrence but not overall healing

Question 30

exercise indicated for.. | with patients with vascular and integumentary disorders in order to

Answer 30

- increase strength (esp. muscle pump) - increase joint ROM - improve QOL perceptions - Increase blood flow to extremities - increase calf pump activity - prevent pressure ulcers - enhance effects of bandaging

Question 31

# What does Exercise: aerobic exercise do for patients with vascular conditions/wounds

Answer 31

- enhances effect of respiratory pump - can help with calf pump - assist with weight loss for patients who are obese - assist with blood sugar control with patient with DM

Question 32

what does Exercise and mobility training do for patients with vascular and integmentary issues

Answer 32

- improves independence and safety - increase perception of mobility - enhance patient's sense of well-being

Question 33

evaluation for vascular wounds

Answer 33

- PMH: specific vascular related events, smoking history, symptoms of claudication, resting pain, limb fatigue - inspection: size, symmpetry (to other limb), cyanosis, clubbing, edema, assess all visible wounds

Question 34

Pitting edme scale

Answer 34

1+ barely percepitble depression (2mm) 2+ 4mm (skin rebounds to its original contour within 15 seconds) 3+ 6mm skin rebounds to its original contour within 15-30 seconds 4+ 8mm (rebound >30 sec)

Question 35

Pulses: scale 0-3+

Answer 35

- 0: absent pulse - 1+: Diminished pulses - 2+ normal pulses - 3+ pathologically prominent pulses of severe aortic insufficiency or if the artery is aneurysmal

Question 36

pulses: scale 0-4+

Answer 36

0: no palpable pulse 1+: faint but detectable pulse 2+ diminished pulse 3+ normal pulse 4+ bound pulse

Question 37

circulation testing ## Footnote capillary refill and ABI: numbers

Answer 37

- capillary refill: pressing on end of toe or skin just proxiumal to wound; normal = < 3 seconds ankle brachial index: - < 0.5 = severe ischemia w/ resting pain refer to specialist - 0.5-0.8 = moderate PAD refer to vascular intermitten claudication - < 0.6 = compression contraindiciated - 0.6-0.8 = modified compression - 0.8-1- mild PAD compression safe to use - 1-1.2 = normal - > 1.2 = refer to specialist calcified vessles in DM

Question 38

Other tests

Answer 38

- rubor of dependency = arterial perfusion: arterial insufficiency foot will blanch hen elevated and take >30 seconds to return pink or turn bright red - venous filling time: venous insufficiency = < 5 seconds, nomral 5-15 second, arterial insufficiency = > 20 seconds - venous patency: percussion test, trendeleburg test - homans sign | `

Question 39

Non-invasive arterial testing

Answer 39

- dopplar US - segmental and digital plethysmography - arterial duplex scanning - transcutaneous oxygen measurements (normal 60-90 mmHg, < 30 = wound can be debrided, 20-30: healing expected but delayed, < 20 = poor prognosis to heal - MRA - commuted tomography angiography