The Vascular Exam

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The Vascular Exam
Jason Davis, MD
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Before the Exam

• Obtain history
• Acute vs. Chronic symptoms
• Distribution of symptoms
• Level(s) of extremity pain, etc.
• Aggravating, Relieving factors
• Activity/rest, elevation/dependence
• Co-morbid conditions, vitals

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Basic Anatomy to Know
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Basic Anatomy to Know
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Basic Anatomy to Know
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Elements of Vascular Exam

• Inspect, Palpate, Auscultate
• Skin pallor/rubor, mottling/ cyanosis,
  temperature, atrophy, hair distribution
• Motor function and sensory exam
• Tissue loss, ulcerations
• Pulse /- doppler exam
• Always compare each w/ contralateral

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Elements of Vascular Exam
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Vascular Exam tips

• Doppler signals are NOT Pulses
• Palpable pulses include carotid, brachial,
  radial, ulnar, femoral, popliteal, dorsalis
  pedis, posterior tib
• Bruits vs. Thrills Audible vs. Palpable
• Characterization of Pulses
• Character (bounding, thready), Rate, Rhythm
• Characterization of Doppler Signals
• Triphasic, Biphasic, Monophasic

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Trauma / Hypovolemia

• If you can palpate
• Radial pulse, then SBP is gt70 - 80
• Femoral Carotid, then SBP gt50 - 70
• Carotid only, then SBP gt40 - 60
• NEVER rely on pulses alone for hypovolemia
  assessment

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Lower Extremity Ulcers

• Arterial (PAD)
• Distal (often at toes), painful, pale
  granulation,
• Assoc w/ atrophy, hairless/shiny skin,
  rubor-pallor
• Venous (VI)
• Lower third, medial malleolus, elevation relieves
• Assoc w/ edema, larger, irregular, moist base
• Diabetic
• Pressure offloading, footwear, self-checks

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Common Vascular Problems

• Peripheral arterial disease
• Thrombotic (DM, atherosclerosis)
• Embolic (atrial fibrillation, Aneurysms)
• Venous insufficiency
• DVT, thrombophlebitis
• Carotid artery stenosis
• Compartment Syndrome
• Trauma

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Compartment Syndrome

• Leg compartments
• Lower Anterior, Lateral, Superficial Deep
  Posterior
• Upper Anterior (extensor), Medial (adducter),
  Posterior (sciatic n.)
• 6 Ps indicating ischemia
• Pain
• Paresthesias
• Palor
• Pulselessness
• Poikilothermia
• Paralysis

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Clinical Scenario 1

• Routine 5pm ED consult for cellulitis.

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Clinical Scenario 1

• Routine 5pm ED consult for cellulitis.
• You see before leaving within your hrs
• On arrival, 78yo male w/ DM, CAD, tobacco
• Also, hx of irregular HR with INR of 1.1
• Rt foot cooler than Lt, no palp Rt DP or PT
• Acute onset severe pain started 3hrs ago
• Embolectomy and anticoagulation
• Dont forget fasciotomy

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Clinical Scenario 2

• New consult for non-healing ulcer, evaluate for
  peripheral arterial bypass.

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Clinical Scenario 2

• New consult for non-healing ulcer, evaluate for
  peripheral arterial bypass.
• Obese 63yo M dialysis w/ DM, HTN
• Legs down in chair, severely edematous
• Advised to elevate and compression garments, but
  does not b/c uncomfortable
• Non-tender medial malleolar ulcer x3 wk
• B/L DP and PT are palpable

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Clinical Scenario 3

• Stat consult to 3A for r/o compartment sx.
• 39yo F s/p cardiac cath via L radial artery
• Cath performed for cough, was normal
• After sheath removed, arm doubled in size
• Nurses want to know when pt going to OR

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Clinical Scenario 3

• Stat consult to 3A for r/o compartment sx.
• 39yo F s/p cardiac cath via L radial artery
• Cath performed for sneezing, found normal
• After sheath removed, arm doubled in size
• Direct pressure applied, bleeding ceased
• Palpable distal pulses were appreciated
• Neurovascular exam intact w/ serial exams
• Arm elevated to facilitate venous return

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Bergers Pet Peaves

• No overnight pre-op IVF unless dehydration
  established or elderly pt AND afternoon case
• Reglan for N/V unless obstruction, espec DM
• Zofran ONLY if nausea refractory to Reglan
• Only attg name on consents except as witness
• Residents can, however, sign blood consents
• SCDs for AAAs only (NOT CEAs, bypasses, etc)
• Vaseline gauze, NEVER iodoform gauze
• Do NOT elevate extremities after access cases
• Increases steal symptoms and neuropathy
• Peri-op edema will resolve, heart level adequate
• Dextran x24hrs for all CEAs EXCEPT Bergers

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Vascular Studies

• Duplex
• Doppler
• B-mode doppler
• ABI/PVR (LEADs)