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A Palliative Approach to Peripheral Vascular Disease/ Gangrene

A Palliative Approach to Peripheral Vascular Disease/ Gangrene. Connie Sarvis RN, BN, MN, CON(c),IIWCC, CWS, FCCWS Skin and Wound Consultant Seven Oaks General Hospital. Peripheral Vascular Disease. PAD OR PVD ? 12-15% OF ADULTS OVER 50 (THOSE SEEKING HELP) PAIN OR INFECTION .

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A Palliative Approach to Peripheral Vascular Disease/ Gangrene

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  1. A Palliative Approach to Peripheral Vascular Disease/ Gangrene Connie Sarvis RN, BN, MN, CON(c),IIWCC, CWS, FCCWS Skin and Wound Consultant Seven Oaks General Hospital

  2. Peripheral Vascular Disease • PAD OR PVD ? • 12-15% OF ADULTS OVER 50 • (THOSE SEEKING HELP) • PAIN OR INFECTION

  3. Prognosis • Symptoms remain stable in about 15/20 cases • Symptoms gradually become worse in 4/20 cases • Symptoms deteriorate severely in 1/20 cases

  4. RISK FACTORS • Advanced Age • Smoking • Diabetes

  5. Other Risk Factors • Obesity • Sedentary Lifestyle • Stress • Heredity • Diet • Hypertension • Hyperlipidemia • Elevated Blood Glucose • Cardiovascular Disease • Cerebrovascular Disease

  6. CAUSES OF PVD • ATHEROSCLEROSIS • INJURY • INFECTION

  7. Signs and Symptoms

  8. Symptoms • Claudication • Pt feels cramping or pain in the back of the calf when walking • As PVD continues to progress, claudication/cramping in the calves occurs even when at rest

  9. Other Pain • If the femoral artery is blocked , then pain may extend up to the thighs and buttocks when walking

  10. Other Signs and Symptoms • Loss of hair growth on entire leg or in patches • Absent pedal pulses (later stage) • Rubor (later) • Elevation Pallor (Later) • Cool Feet • Delayed capillary refill

  11. ABI’s Measures Vascular Perfusion Doppler Assessment

  12. How is it Measured? • Blood Pressure (Systolic only taken on both arms • Blood Pressure (Systolic only taken on both ankles • Doppler is used (8 mgHz) • Arm – Brachial pulse is used • Legs – Dorsalis Pedis is used

  13. How Do You Get the Number? Formula (ABI) Ankle Pressure Brachial Pressure

  14. But what do the numbers Mean? • Result of <0.5 = Ischemia • Result of 0.5 – 0.8 = Moderate Ischemia • Result of 0.8 – 1.0 = Mild Ischemia/Normal • Anything over 1.0 is either normal or may indicate calcified arteries in Diabetics. • In this case toe pressures are indicated

  15. Why Might Toe Pressure Numbers Differ? Microcirculation vs Macrocirculation!

  16. Results • 55 mmHg = >0.6 toe brachial index (Low Risk) • 40 mmHg = >0.4 toe brachial index (Mod. Risk) • 20 mmHg = >0.2 toe brachial index (High Risk) <20 mmHg = < 0.2 toe brachial index (Severe Risk) If trying to heal an ulcer on the heel, then poor vascularization in the toes is not as critical

  17. BUT…. How do we differentiate between ulcers that will heal and those that need palliative care?

  18. What happens to an Arterial Wound?

  19. Remember! SKIN IS THE TISSUE MOST RESISTANT TO ISCHEMIA AND SO IS USUALLY THE LAST TO UNDERGO NECROSIS!!

  20. Often times the vascular status is discovered only when trauma occurs and there is not enough vascular perfusion to heal the wound

  21. TREATMENT • Depends upon patient’s condition • Only curative treatment is surgical intervention • Otherwise medical management is preferable

  22. Surgical Procedures • Femoral Popliteal Bypass • Angioplasty • Plaque excision • Stent

  23. OF COURSE SURGERY MAY HAVE ITS’ DRAWBACKS TOO!!

  24. Remember!IF SURGERY IS UNDERTAKEN – THERE IS A FRESH BLOOD SUPPLY FOR ANY RESIDENT BACTERIA! = INFECTION!!

  25. Conservative Treatment Cadexomer Iodine and Povidine

  26. Other Measures? • Viagara?? • Low Dose ASA to prevent clots • Statin Medication to lower plaque buildup

  27. GANGRENE • decay of body tissues • caused by infection/ischemia/thrombus • can be black, brown or green • Malodorous!! • Generally associated with Diabetics and Smoking • Frostbite

  28. DRY GANGRENE • BEGINS AT DISTAL PART OF LIMB DUE TO ISCHEMIA • OFTEN IN THE TOES OF ELDERLY PEOPLE • SPREADS SLOWLY • APPEARS BLACK, SHRUNKEN (MUMMIFIED) • PT. HAS DULL ACHE AND SENSATIONS OF COLDNESS • IF CAUGHT EARLY AND REVASCULARIZED – SOMETIMES THE LIMB/DIGIT CAN BE SALVAGED

  29. DRY GANGRENE

  30. WET GANGRENE • Generally occurs in moist tissue and organs • Tissue is infected by bacteria which have a putrid smell to them • Develops quickly due to arterial and/or venous blockage • Toxic products of bacteria responsible for sepsis – death.

  31. BUERGER’S DISEASE

  32. LOCAL WOUND CARE • Keep wound Dry • Do NOT cleanse with saline first (gangrene) • Do not use Eusol, Saline soaks or Hydrogen Peroxide, Gel’s.

  33. Other Comfort Tips • Avoid tight footwear/binding clothing/dressings • Hang foot down (at night) • Encourage smoking cessation • Avoid trauma

  34. Pain • Fentanyl pre-dressing change • Systemic pain relievers • Gapapentin • Morphine/gel?

  35. Infection • Keep gangrenous/arterial area as dry as possible • Patients very prone to developing osteomyelitis as ulcers can be quite deep • Povidine – Don’t dress until dry • Tightly woven dressings better (no loose fibres)

  36. GOAL • Prevent Pain! • Prevent Infection! • Prevent Amputation!

  37. Questions?

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