Term
first line for pts with PAD?
mx for PAD? |
|
Definition
clopidogrel
those with risk factors for CVS should be on statins.
MX: clopidogrel, supervised exercise training program. |
|
|
Term
| how can severe PAD or critical limb ischema be treated? |
|
Definition
angioplasty
bypass
stenting |
|
|
Term
| when should you consider amputation in critical limb ischemia? |
|
Definition
| when they aren't suitable for angioplasty or bypass surgery |
|
|
Term
| name 2 drugs other than clopidogrel that are licensed for use in PAD? |
|
Definition
Naftidofuryl oxalate: it is a vasodilator sometimes used for pts with poor QofL.
Cilostazol: phosphodiesterase III inhibitor with anti platelet and vasodilator effects. |
|
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Term
|
Definition
a ratio of systolic BP in lower leg to that of the arm.
Lower BP in legs result in ABPI <1 |
|
|
Term
| why is it important to determine ABPI in those with leg ulcers? |
|
Definition
| venous ulcers often treated with compression bandage. doing this to someone with PAD can be harmful as it further restricts their blood supply to the foot. |
|
|
Term
| describe interpretations of ABPI |
|
Definition
> 1.2 may indicate calcified stiff arteries. seen in old age or PAD
1 - 1.2 is normal
0.9-1 is acceptable
< 0.9 is likely PAD
< 0.5 severe disease that needs referring urgently. |
|
|
Term
if someone had a venous ulcer and you wanted to put a compression bandage on what does the ABPI have to be in order for it to be ok to have a compression bandage?
how can compression bandages be bad in someone with ulcers and PAD? |
|
Definition
> 0.8 and its ok to put on compression bandages.
they are bad in someone with ulcers and PAD because the bandages can further restrict the blood flow. |
|
|
Term
what is the most severe manifestation of PAD affecting a limb?
what is the definition of critical limb ischema? |
|
Definition
Critical limb ischemia.
definition: presence of ischemic rest pain and ischemic lesions or gangrene that is objectively attributable to arterial occlusive disease. |
|
|
Term
calf claudication in PVD suggests the disease is in which arteries?
if claudication was in the buttock where does this suggest the disease is? |
|
Definition
calf claudication - femoral arteries
buttock claudication - illiac arteries |
|
|
Term
what is Leriche's syndrome?
what is it caused by? |
|
Definition
buttock claudication and impotence.
it is caused by a saddle embolus at aortic bifurcation. |
|
|
Term
| smoking related inflammation and thrombosis of veins and middle sized arteries is better known as? |
|
Definition
|
|
Term
define critical ischemia.
what classification system is used for critical ischemia? |
|
Definition
Ulceration, gangrene and foot pain at rest. there is burning foot pain that is relieved by hanging the feet over the bed.
The Fontaine classification system is used to categorise critical ischemia.
1. asymptomatic
2. intermittent claudication
3. ischemic rest pain
4. ulceration/gangrene (critical ischemia) |
|
|
Term
| signs of critical ischemia |
|
Definition
absent femoral/popliteal or foot pulses.
cold white legs
atrophic skin
punched out ulcers
postural dependent colour change |
|
|
Term
| what is Beurger's angle in critical ischemia? |
|
Definition
< 20 degrees
also CRT is > 15 seconds |
|
|
Term
tests and ix in PVD
what diseases should you exclude?
which tests would you do to exclude them?
what conditions should you ix for if the pt is < 50? |
|
Definition
ABPI
exclude DM
exclude arteritis with CRP/ESR
exclude anemia and polycythemia
renal disease with U and E
dyslipidemia by checking lipids
cardiac ischemia by doing ECG
if pt < 50 ix for thrombophilia and homocysteine |
|
|
Term
| in ABPI what measure is critical limb ischemia |
|
Definition
< 0.5
or systolic < 50 mmHg |
|
|
Term
| in which condition can you get falsely high results in ABPI? what is this due to? |
|
Definition
DM gives falsely high results in ABPI.
this is due to incompressible calcified vessels. |
|
|
Term
what is the first line imaging in PVD?
if you are considering treatment what ix can you do to see the location and extent of the stenosis? |
|
Definition
colour doppler USS is 1st line.
MRI/CT angiography can be used if you are considering rx. it allows you to see the location and extent of the stenosis and quality of distal vessels AKA run off. |
|
|
Term
|
Definition
stop smoking
treat HTN and high cholesterol
1st line medicine is clopidogrel. |
|
|
Term
| what should the duration of supervised exercise programs be? |
|
Definition
| 2hours per week for 3 months. it reduces symptoms by improving collateral blood flow. |
|
|
Term
| in PVD if disease is limited to a single artery then what treatment can be given to increase the patency of this artery? |
|
Definition
percutaneous transluminal angioplasty (PTA)
a ballon is used to inflate the artery and stents can be used to maintain latency |
|
|
Term
| what types of bypass grafts are available in atheromatous PVD? |
|
Definition
femoral popliteal bypass
femoral femoral cross over
aorto bifemoaral bypass. |
|
|
Term
what % of intermittent claudication need amputation in 5 years?
what can increase the risk to needing an amputation? |
|
Definition
<3%.
DM increases the risk of needing an amputation |
|
|
Term
what are the indications for amputation
in an amputation what should you try and preserve and why?
what can be used for phantom pain? |
|
Definition
intractable pain
to save pt from death or from sepsis or gangrene
Try to preserve the knee joint as it improves mobility and rehab potential.
Gabapentin can be used for phantom pain. |
|
|
Term
causes and signs and symptoms of acute limb ischemia
which sign implies irreversible damage? |
|
Definition
causes: Thrombus, emboli, graft-angioplasty occlusion and trauma
6 P
pale
painful
paraesthesia
pulseless
paralyzed
perishingly cold.
onset of fixed mottling implies irreversibility. |
|
|
Term
| in a known vasculopath what is the likely cause for acute limb ischemia? |
|
Definition
|
|
Term
management of acute limb ischemia.
post op care?
complications? |
|
Definition
surgery or angioplasty
if dx doubt do arteriography
thrombus: thrombolysis
emboli: embolectomy
post op give heparin and look for root cause.
complications: reperfusion injury, compartment syndrome. |
|
|
Term
| name some fixed risk factors for PVD |
|
Definition
FHx
Male
Early menopause
ethnicity PK, BD, IN, SL
Age |
|
|
Term
| in severe PVD where is the pain usually? Clue: not so much the calves. |
|
Definition
| Pain is more in the toes and feet |
|
|
Term
|
Definition
6-7 times increased risk of MI, angia or stroke
increased chance of atheroma in other vessels. |
|
|
Term
| which two medications can be used in pts with PVD who have not improved with exercise and are not suitable candidates for surgery? |
|
Definition
| Cilostazol and naftidrofuryl. They open up arteries but are not effective in all pts. |
|
|
Term
| list the main 3 operations for pVD |
|
Definition
angioplasty
bypass
amputation |
|
|
Term
| pre op assesment in pt undergoing limb amputation |
|
Definition
psychological eval
check condition of good limb as sometime amputation can put extra strain on the good limb
check home work environment to assess if they need extra help
introduce the physio and OT who will be involved in their care.
after the operation it may be several months before prothesis is fitted. the pt may be given a wheelchair for this time.
follow up appointments are important to see how the pt is coping and to suggest support groups.
before the pt is discharged, the OT may visit their home to see if they need additional care, if so they will contact the social support guys. |
|
|
Term
|
Definition
| it is when the remaining muscle after an amputation is done is stitched to the bone. this can help to strengthen the remaining limb. |
|
|
Term
|
Definition
require hard work to learn to balance and adjust using a prosthesis.
there are prosthesis available for cosmetic purposes for those who cannot stand the strain of using a prosthesis. these are just to look the part but cannot be used to weight bear. |
|
|
Term
| describe activities pts do from hospital in order to prepare to receive their prosthetic |
|
Definition
physio starts teaching them exercises to strengthen their stump.
The stump is desensitised by tapping with a face cloth and compression bandages. care is taken so scar tissue doesn't build up around the stump.
take care of the good remaining limb especially if the amputation was due to diabetes. |
|
|
Term
| complications of amputations |
|
Definition
infection, slow healing
MI , DVT
phantom limb pain
further surgery needed if pain thought to be due to neuroma and cluster of nerves involved need to be removed. |
|
|
Term
|
Definition
NSAIDs - ibuprofen
anticonvulsants - carbamazapine, gabapentin
antidepressants - amitriptyline
opioids
local steroid injections
TENS and acupuncture may help |
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