C: Week 2

Question 1

Arterial Wound

Answer 1

• Wound that results from a lack of blood flow which deprives the area of oxygen
• 5%-10% of all LE ulcerations are because of arterial insufficiency

Question 2

Arterial vessels outer most layer to inner most layer

Answer 2

1.)Tunica Adventita= protective layer + supportive outer layer
2. Tunica Media=
3.) Tunica Intima= delicate layer in contact with the blood cells

Question 3

Acute Embolism (Etiology of Arterial Insufficiency)

Answer 3

A clot stops blood flow to an area + damages arteriole wall when a clot gets stuck

Question 4

Thromboangiitis Buerger’s Disease (Etiology of Arterial Insufficiency)

Answer 4

• Inflammation of the small vessels
• When inflamed they can include things like swelling which makes them close off

Question 5

Atherosclerosis (Etiology of Arterial Insufficiency)

Answer 5

Thickening or hardening of arteries
- #1 reason for Arterial Insufficiency

Question 6

Atherosclerosis (Etiology of Arterial Insufficiency)

Answer 6

-Systemic process by which the vessels narrow
- lipids + calcium deposits + scar tissue accumulate on the inner lining of the arteries and narrow the lumen- stenosis
-High LDL’s lead to a deposition of plaques into the arteries

Question 7

Intermittent Claudication

Answer 7

• It is activity specific discomfort due to local ischemia
• Pain stops within 1-5 minutes of ceasing activity
• Pain location is usually distal to the site of occlusion
• Demand of O2 exceeds what they can supply

Question 8

If there is intermittent claudication in the Iliofemoral artery obstruction where would the person feel the pain?

Answer 8

Buttock, thigh, calf pain

Question 9

If a person had a Infrapopliteal artery obstruction where would they feel the pain?

Answer 9

foot pain

Question 10

Ischemic Rest Pain

Answer 10

• More significant arterial disease
• Burning pain exacerbated with elevation and relieved by dependency
• Increasing Tissue O2 demand can fatally upset the balance between O2 supply and tissue demand causing ulceration

Question 11

The progression of Arterial Insufficiency

Answer 11

Arterial Insufficiency–> Intermittent Claudication–> Ischemic rest pain –> Ulcer

Question 12

Gangrene

Answer 12

• when oxygen supply does not equal demand you have cell death
• dead tissue typically dry, dark, cold, and contracted
  -Dry= stable its ok (good), circulation, proximal, keep it dry
• Wet not good

Question 13

Diabetes (Etiology of Arterial Insufficiency)

Answer 13

• Arteries tend to accumulate calcium making them harder + narrowing the openings of the vessels -stenosis
  -prolonged hyperglycemia impairs angiogenesis, fibroblast proliferation, collagen synthesis and overall strength of scar tissue and impairs all 3 phases of healing

Question 14

What is the A1c level of a normal person and a diabetic

Answer 14

Normal= 5.7
Diabetic= anything less than 7

Question 15

Difference between neuropathic wound and an arterial wound

Answer 15

Neuropathic wound happens over points of pressure like a bed sore

Arterial wound happens from ischemic tissue dying and forming an ulcer

Question 16

Characteristics of an Arterial Wound

Answer 16

1. Pain- severe unless masked by neuropathy- pain increases with elevation
2. Position- Primarily LE, Distal toes, Dorsal Foot, areas of trauma
3. Presentation
   –> Regular appearance
   –> may conform to precipitating trauma
   –> pale granulation tissue if present
   –> Black eschar
   –> gangrene
   –> little to no drainage
4. Periwound & Extrinsic Tissue
   –> thin, shiny, anhydrous skin
   –> loss of hair growth
   –> thickened yellow nails
   –> pale, dusky, or cyanotic skin
   –> dependent rubor
   –> edema unusual, may indicate VI or CHF
5. Pulses- decreased or absent pedal pulse
6. Temperature- cool/decreased

Question 17

Wound Presentation Arterial Insufficent Wounds

Answer 17

• Begin small and shallow
• Round and regular or conform to trauma
• Any granulation tissue will be pale or grey
• Necrotic tissue desiccated with black eschar or yellow if bandaged for wound moisture
• Minimal to no wound drainage even with infection

Question 18

Physical Therapist Tests for Arterial Insufficiency

Answer 18

1. Pulses
2. Doppler Ultrasound
3. ABI
4. Rubor of Dependency
5. Capillary Refill
6. Venous Filling Time

Question 19

Doppler Ultrasound

Answer 19

• Indications: decreased or absent pulses
• Helpful in assessing arterial Patency
• method of assessment when pulses cannot be palpated easily

Question 20

ABI Indications

Answer 20

• Decreased/absent pulses
• Signs/symptoms of AI
• History of PVD

Question 21

ABI 1.1-1.3 =

Answer 21

• vessel Calcification
• ABI is not a valid measure of tissue perfusion
• Referral to vascular

Question 22

ABI 0.9-1.1=

Answer 22

• Normal
• Okay to debride

Question 23

ABI 0.7-0.9=

Answer 23

• Mild to moderate Arterial Insufficiency
• Conservative interventions normally provide satisfactory wound healing
• 0.8-0.5: clinical judgment required for debridement

Question 24

ABI 0.5-0.7=

Answer 24

• Moderate arterial insufficiency, intermittent claudication
• May perform trial of conservative care, physician may consider revascularization
• 0.8-0.5: clinical judgment required for debridement

Question 25

ABI <0.5 =

Answer 25

- Severe arterial insufficiency, rest pain - Wound is unlikely to heal without revascularization, limb threatening arterial insufficiency - <0.5 referral to vascular surgeon

Question 26

ABI <0.3 =

Answer 26

- Rest pain and gangrene - Revascularization or amputation

Question 27

Arterial Insufficiency Medical and surgical interventions

Answer 27

- Prescription drugs - Revascularization - Percutaneous Balloon Angioplasty= procedure in which balloon tip catheter is expanded at a site of stenosis: compressing any of the plaque formation that is obstructing the blood flow against the wall and then opening the vessel - Amputation: earlier is better than later in terms of healing potential

Question 28

Physical Therapy Management for Arterial Insufficiency

Answer 28

- Limb protection from trauma, chemicals, excessive heat/cold, protect open wounds, live healthy - Therapeutic exercises: strengthening, aerobic exercise, stretching, positioning, gait training and mobility

Question 29

Venous Insufficiency Definition

Answer 29

- Condition where the veins particularly in the lower extremities have difficulties sending blood back to the heart

Question 30

Type of Veins: Deep

Answer 30

- Popliteal - Femoral - Tibial Carry 80-90% of blood back to the heart

Question 31

Type of Veins: Superficial

Answer 31

- Greater/Lesser Saphenous veins - Drain skin and subcutaneous tissues - Assist with temperature regulation -

Question 32

Type of Veins: Perforating Veins

Answer 32

- Connect deep and superficial veins - 60-100 perforating veins in each leg

Question 33

True false: Venous insufficiency is a low pressure system

Answer 33

True

Question 34

Calf muscle Pump

Answer 34

Main way we get blood back to the heart+ calf muscle contracts the veins get compressed blood forced up leg

Question 35

Respiratory Pump

Answer 35

Every time we inhale/exhale - Inhale = decrease in thoracic pressure + increase in abdominal pressure which provides a pressure gradient to drive blood back to the heart

Question 36

Valves

Answer 36

present to prevent retrograde blood flow (backwash)+ preventing increase venous back pressure (venous hypertension)

Question 37

What are the common causes of Venous hypertension?

Answer 37

- Vain dysfunction - incompetent superficial and perforating veins - Valve damage - Calf muscle pump failure

Question 38

White Blood Cell Trapping Theory

Answer 38

- congestion + distention is caused by venous hypertension - distention encourages WBC's to come to the area which further increases congestion - WBC's adhere to the vessel walls and become trapped - Trapped WBCs trigger inflammatory response which encourages more cells to an already congested area -WBCs releasing substances that further damage the epithelial lining of the veins - Ulcer will ultimately develop from local hypoxia caused by the trapped WBCs

Question 39

Fibrin Cuff Theory

Answer 39

The distention caused by venous hypertension will make the veins leaky - Leaky veins allow proteins and fluids to escape into interstitial tissue causing swelling and edema - Fibrinogen is leaked once in the interstitial it will convert fibrin - Which then adheres to the capillary walls forming a cuff - Cuff then prevents O2 + nutrients exchange to the skin so the skin dies and ulcer develops

Question 40

Venous Insufficiency Ulcer: Pain

Answer 40

- mild to moderate unless masked by neuropathy - decreases with elevation /compression

Question 41

Venous Insufficiency Ulcer: Position

Answer 41

- Medial Malleolus - Medial Leg - Areas of Trauma

Question 42

Venous Insufficiency Ulcer: Presentation

Answer 42

- irregular shape - Fibrous, glossy coating - Red, ruddy wound bed - Copious drainage

Question 43

Venous Insufficiency Ulcer: Peri wound and Extrinsic Tissue

Answer 43

- Edema - Dermatitis and cellulitis common Hemosiderin staining Lipodermatosclerosis

Question 44

Venous Insufficiency Ulcer: Pulses

Answer 44

- Normal or decreased due to edema or concomitant arterial insufficiency

Question 45

Venous Insufficiency Ulcer: temperature

Answer 45

- Normal to mild warmth