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TCD 21: Limb Problems By Zakariya Mouyer, Nazneen *Disclaimer* The content of this presentation was created by med students for med students. This session isn’t intended to replace any formal education provided by the uni of mani, so make sure to review all the cases on 1Med and read your ILOs and attend at least 40 hours/week of clinical experience ;)Admin Stuff - Youknowthedrill - Anyadminstuffpleaseemailscrubbed-up@outlook.comrather thanmessagingoneofuspersonally:)) - Stopcomplainingabouttheheatingomlenjoyitwe’relegitina costoflivingcrisisrntellmeurrichwithouttellingmeurrichLife rnSo what is this teaching exactly? Covers the main pathologies mentioned in each week’s TCD Progress Test, CCA/OSCE, DDx, top notch medics basically NOT HERE TO HOLD YOUR HAND THROUGH THE 1MED CASES SUCCINCT, HIGH YIELD, SHARP and ACCO IT’S نﺎﺳﺣإ SEASON PEOPLE !! No advice. Just pain. Morale is low. Discipline is a must. Contents ❏ PoopiepooppooplotsofpoopjustloadsofpoopeverywherepoopiepoopPeripheralVascular DiseasePeripheralArterial Disease ● Atherosclerosisisinevitable:withageweareexposedtoshearstress, endothelialtoxins,andotherformsofdamage ● Thisleadstoactivationofourimmunesystemleadingtoinflammation ● Fatandgranulationtissuedevelopswithinourvessels, reducingthe lumendiameter ● Thiscangraduallyleadtoischaemia,or,iftheplaqueruptures,acute ischaemia Riskfactors? Diabetes, smoking, age, male, family history, high cholesterol, hypertension. Ask about these in any cardiovascular/vascular history.Claudication NB:youmayhearpeoplewithclaudicationreferredtoas"claudicants" Youcanthinkofclaudicationasanginabutforothermuscles.Ifapatient hasenoughatherosclerosisin,forexample,thearterythatsuppliestheir calfmuscles,tothepointwherenotenoughoxygencanbedeliveredto meetthedemandsofexercise,thepatientwillexperiencepainon movement -thismightbeimmediateorafteracertainamountofactivity. Leriche Syndrome • Aka aortoiliac occlusive disease – blockage of the abdominal aorta as it becomes the common iliacs • Results in a triad of: • Buttock and thigh claudication • Absent or decreased femoral pulses • Erectile dysfunctionThe Fontaine Classification 1. Nosymptoms 200 2. Claudication-"2a"ifpainonwalkingmorethan_________m_;"2b"ifpainon walkinglessthan___200__. 3. Rest/nocturnalpainm 4. Tissueloss/gangrene So how can we treat this? ● By aggressively targeting risk factors: stop smoking, control diabetes, weight loss, (aspirin 75mg OD).ion (statin), BP control (I.e. "A or C"), and anti-platelet therapy If they follow this, they can become better in a year as a collateral circulation develops (basically they create their own bypass). If left untreated, the ischaemia will progress and eventually lead to limb loss.ABPI: Ankle-Brachial Pressure Index  Thisistheratioofbloodpressureattheankletobloodpressureatthe arms(calculatedassystolicBPofankle/systolicBPofarm)[thepatient MUSTbesupine,ortherewillbefalseresults] Whatisthenormalrange? 1.0 - 1.2 Ascorebelowwhatisusuallyworthinvestigating? 0.9 (0.91-0.99 is acceptable) Whatmightcauseascoreofabove1.3? Arterial calcification ● Below 0.9 suggests some arterial disease. ● Below 0.5 is severe arterial disease. ● Above 1.3 is suggestive of diabetic calcification or peri-occlusive arteriosclerosisABPI: Ankle-Brachial Pressure Index - for people who learn by eyes >1.2 ~Calcified/stiff arteries --> PAD/old age 1-1.2 Normal <0.9 PAD <0.5 Severe PAD - <0.4 CI for stockings <0.3 Critical limb ischaemia --> urgent referralBuerger's Test Buerger's disease: Performifcriticallimbischaemiaissuspected AKA thromboangiitis ● Raisebothfeetto45degreesandlookforanycolour obliterans - vasculitis change(healthywillstaypinkuntil90degrees) Is recurrent and progressive ● Ifthereisanycolourchangetopale–notetheanglethis inflammation of occursat–thisisBuerger'sangle medium and small ● Thenaskthepatienttodangletheirlegsovertheedgeof arteries strongly thebed–youwillseeareactivehyperaemiaastheleg changescolourbacktonormal,firstgoingred.Thisis associated with Buerger'ssign. tobacco use. It basically stops with smoking cessation. PeripheralArterial Disease: Signs & Symptoms ● Pain(hangingfootoff • "Punched out" bedatnight) • Painful ● Slowhealingwounds • Circular/delineated ● Arterialulcers • Red, yellow, or black ● Discolouration  • Deep ● Hairloss ● Claudication  ● Brittletoenails No singular treatment for arterial ulcers. Just good wound care (dressings) and then taking steps to prevent further ones (I.e. treating peripheral arterial disease)Acute Limb Ischaemia We'vediscussedtheconsequencesofatherosclerosis,butwhathappensif thisplaqueruptures?Theplaquecantravelfurtherdownstreamand causesablockageofasmallerartery. Aclassicexampleofthisisbluetoesyndrome:whereamicroembolus blocksoffthebloodsupplytoatoe,causingacuteischaemia. Whatarethesignsofacuteischaemia? The 6 Ps: - pulseless These changes are reversible up to embolectomy via Fogarty around 4 hours. At hour 4, catheter, surgery - pain paraesthesia will occur. Paralysis (bypass), thrombolysis - pale tends to occur at around 6 hours - poikilothermia* and at this point the tissue is *Just means cold - paraesthesia - paralysis generally non-salvageable.PAD Rx - long term ting EVERYONE WITH PAD: -Supervise exercise programme (exercise to point of symptoms 30mins 3-5x a week) - Clopidogrel 75mg (2nd line 75mg Aspirin) - Manage CV risk (2ndary prevention) IF NO IMPROVEMENT WITH EXERCISE PROGRAMME: Angioplasty/Bypass Surgery (of leg not the heart lol, yes ppl make this mistake smh) - if unable - then naftidrofuryl oxalate - peripheral vasodilator - stop if no benefit after 6/12 Reminder on 2ndary prevention in CVD 1st-line 2nd-line ACS -Aspirin (lifelong) + prasurgrel/ticagrelor Aspirin + clopidogrel (lifelong) (12 months). -If PCI --> prasugrel preferred Stroke/T -Clopidogrel (lifelong) -Aspirin + dipyridamole (lifelong) IA PAD -Clopidogrel (lifelong) -Aspirin (lifelong)Carotid Endarterectomy Ahugerisktopeoplewithperipheralvascular diseaseiscardiovascularandcerebrovascular disease.Wemustalwaysthinkabouttheirriskof MIorstroke.  Ifpatientshavesymptoms(e.g.astroke,TIA, amaurosisfugax),ormorethan_______stenosis(as foundonduplexscanning),wecanperforman endarterectomy. Otherwise,wecontinuewithmedical management.Venous Insufficiency Notonlycanwehaveproblemswithourarteries,butalsowithourveins. Chronicvenousinsufficiencyoccurswhentheveinscannotreturnblood fromthelegstothehearteffectively,leadingtopooling.Whatarethe signsofCVI? This is when iron released from the pooled red - Oedema blood cells stains the skin - Haemosiderosis Subcutaenous fat becomes irritated - Venous ulcers and inflamed. It eventually hardens. - Lipodermatosclerosis - Itching The skin becomes dry and flakey, - Venous eczema predisposing to ulcers. - Atrophie blanche White plaque-like scars with red spots (enlarged capillaries)Venous Insufficiency: Signs Atrophie Blanche Haemosiderin Staining Venous ulcer: - more shallow and proximal - classically "painless" - not well circumscribed - "sloughed" edges Lipodermatosclerosis (with inverted Venous eczema champagne botttle sign)Venous Insufficiency Causes and Management Chronicvenousinsufficiencyisusuallytheconsequenceofveinpathology,for exampleDVTs(e.g.post-thromboticsyndrome)orphlebitis. Wecanmanageitbygivingcompressionstockings–thisencouragesvenous bloodflow.Wecangivepentoxifyllineasanadjuncttoo. Insomepatientswemaynoticetheirulcersaretakingalongtimetoheal. ThismaybebecausetheyhavePADtoo.WecanthenperformanABPIto investigateit. Thereforecompressionstockingsareabadideabecauseit willfurtherreducearterialbloodflow,whichisrequiredforhealing.DVT Deep Vein Thrombosis (DVT) Thisisabloodclotinadeepvein(veinsthataccompanynamedarteries)[therearen’t manyofthese],usuallyintheleg beingimmobilefora while,varicoseveins trauma,hypertensive cancer,pregnancy, damage,infections bloodconditions Killsmanypeopleeveryyearandiscommonamongstinpatients.Soallpatientsshould berisk-assessedfordevelopingaDVT(wewillgettothis),andgivenprophylaxisas mentioned. Whatcanwegiveasprophylaxis? DOAC/LMWH and thrombophylactic stockings/flowtrons *Homan's sign is pretty useless. Only reason we DVT Signs and Symptoms low sensitivity and specificity, and there is somea very worry that it may be dangerous in that it could theoretically dislodge a thrombus Name some signs  How about risk factors? and symptoms: ● calfwarmth ● pregnancy ● calftenderness ● Trauma ● calfredness ● Surgery ● mildfever ● immobility** ● pittingoedema ● pastDVT ● sizediscrepancy ● varicoseveins ● cancer (>3cm,10cmbelow ● obesity tibialtuberosity) ● Thrombophilia ● oralcontraceptivepill Homan's sign*: pain on dorsiflexion **The calves act as pumps: when they contract they squeeze blood to the heart. When we are not moving (e.g. long haul flight, recovering in bed) we do not use our leg muscles and the blood is subject to stasis.Differentials and Diagnosis InanOSCEhistorytakingstationyouwill usuallybeasked:"whatisyourmostlikely diagnosis,andwhataretwodifferentials?" WhataredifferentialsforaDVT? Howdowediagnoseit? ● CalculatetheWell'sscore -Cellulitis(veryrarelybilaterally!) ● ≥2:USSwithin4hrsorD-dimerand -Baker'scyst  anticoagwithUSSin24hrs ● ≤1:D-dimer-if+vedoUSS D-dimersareafibrindegradationproduct. Theyarenotpresentinthebloodunlessthe coagulationcascadehasbeenactivated. Thetestisverysensitive,butnotspecific.It doesnotguaranteethecauseisaDVT,butthe absencerulesoutaDVT.Youdon'tneedtoknowthe Well'sscore offbyheart! I'vejustincludeditherefor yourinterest.  Youdoneedtoknowhowever: 1orless=unlikely 2ormore=likely=ordera D-dimer/USSwithin4hrs IfD-dimernegative;DVThas beenruledout. DVTTreatment DOACs(examples?)first-line ShouldbestartedonceDVTissuspectedandcontinuedifconfirmed LMWHifDOACiscontraindicated(hepaticdisease,severerenalimpairment) Provoked(weknowthereason) DOAC/LMWHfor3months Temporarycause(postsurgery) Provoked LifelongwarfarinwithINR2-3 Permanentcause(clottingdiseases) INR3-4ifrecurrenceofDVT Unprovoked(wedon’tknowthereason) DOAC/LMWHfor6months,investigatecause Resources - BMJBestPractice - Zerotofinals - TCD - Eeznuts - Geekymedics - OxfordHandbookofRespiratoryMedicine - FocusedHistoryTaking - ExaminationsBooklet-howtoelicitsignstoseeifshelikesmeornot? - Bofadee - Znuts - Drugbank - MyownnotesTysm :)