The Vascular Exam

Jason Davis, MDJason Davis, MD

Before the Exam…Obtain historyAcute vs. Chronic symptomsDistribution of symptoms

Level(s) of extremity pain, etc.Aggravating, Relieving factors

Activity/rest, elevation/dependenceCo-morbid conditions, vitals

Basic Anatomy to Know

Basic Anatomy to Know

Basic Anatomy to Know

Elements of Vascular Exam

Inspect, Palpate, AuscultateSkin pallor/rubor, mottling/ cyanosis,

temperature, atrophy, hair distributionMotor function and sensory examTissue loss, ulcerationsPulse +/- doppler exam

Always compare each w/ contralateral

Elements of Vascular Exam

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

Trauma / Hypovolemia■ If you can palpate:

– Radial pulse, then SBP is >70 - 80– Femoral + Carotid, then SBP >50 - 70– Carotid only, then SBP >40 - 60

■ NEVER rely on pulses alone for hypovolemia assessment

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

Common Vascular Problems■ Peripheral arterial disease

– Thrombotic (DM, atherosclerosis)– Embolic (atrial fibrillation, Aneurysms)

■ Venous insufficiency■ DVT, thrombophlebitis■ Carotid artery stenosis■ Compartment Syndrome■ Trauma

Compartment Syndrome

■ Leg compartments– Lower: Anterior, Lateral, Superficial & Deep Posterior– Upper: Anterior (extensor), Medial (adducter), Posterior

(sciatic n.)

■ 6 P’s indicating ischemia– Pain– Paresthesias– Palor– Pulselessness– Poikilothermia– Paralysis

Clinical Scenario #1■ Routine 5pm ED consult for cellulitis.

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

■ Don’t forget fasciotomy

Clinical Scenario #2■ New consult for non-healing ulcer, evaluate

for peripheral arterial bypass.

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

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

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

Berger’s 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■ SCD’s for AAA’s only (NOT CEA’s, 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 CEA’s EXCEPT Berger’s

Vascular Studies■ Duplex

■ Doppler

■ B-mode doppler

■ ABI/PVR (LEADs)