A Palliative Approach to Peripheral Vascular Disease/ Gangrene

Connie SarvisRN, BN, MN, CON(c),IIWCC, CWS, FCCWS

Skin and Wound ConsultantSeven Oaks General Hospital

Peripheral Vascular Disease

PAD OR PVD ?

12-15% OF ADULTS OVER 50

(THOSE SEEKING HELP)

PAIN OR INFECTION

Prognosis

Symptoms remain stable in about 15/20 cases

Symptoms gradually become worse in 4/20 cases

Symptoms deteriorate severely in 1/20 cases

RISK FACTORS

Advanced Age

Smoking

Diabetes

Other Risk Factors Obesity

Sedentary Lifestyle

Stress

Heredity

Diet

Hypertension

Hyperlipidemia

• Elevated Blood Glucose

• Cardiovascular Disease

• Cerebrovascular Disease

CAUSES OF PVD ATHEROSCLEROSIS INJURY INFECTION

Signs and Symptoms

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

Other Pain If the femoral artery is blocked ,

then pain may extend up to the thighs and buttocks when walking

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

ABI’s

Doppler Assessme

nt

Measures

Vascular

Perfusion

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

How Do You Get the Number?

Formula (ABI)

Ankle Pressure

Brachial Pressure

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

Why Might Toe Pressure Numbers Differ?

Microcirculation vs Macrocirculation!

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

BUT….

How do we differentiate between ulcers that will heal

and those that need palliative care?

Characteristic Arterial Venous

Location Usually distal(Top of foot)

Above malleolus

Size Small/punched out

Can be quite large

Shape/Margins

Round/Smooth

Irregular

Depth Can become quite deep

Usually shallow

Wound Bed Base

Pale pink – grey

Variable – usually beefy red

Surrounding Skin

Pale Pigmented

What happens to an Arterial Wound?

Remember!

SKIN IS THE TISSUE MOST RESISTANT TO ISCHEMIA AND SO IS USUALLY THE LAST TO

UNDERGO NECROSIS!!

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

wound

TREATMENT Depends upon patient’s condition

Only curative treatment is surgical intervention

Otherwise medical management is preferable

Surgical Procedures Femoral Popliteal Bypass Angioplasty Plaque excision Stent

OF COURSE SURGERY MAY HAVE ITS’ DRAWBACKS TOO!!

Remember!IF SURGERY IS UNDERTAKEN –

THERE IS A FRESH BLOOD SUPPLY FOR ANY RESIDENT BACTERIA! = INFECTION!!

Conservative Treatment

Cadexomer Iodine and Povidine

Viagara?? Low Dose ASA to prevent

clots Statin Medication to lower

plaque buildup

Other Measures?

GANGRENE decay of body tissues

caused by infection/ischemia/thrombus

can be black, brown or green

Malodorous!!

Generally associated with Diabetics and Smoking

Frostbite

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

DRY GANGRENE

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.

BUERGER’S DISEASE

LOCAL WOUND CAREKeep wound DryDo NOT cleanse with saline first (gangrene)Do not use Eusol, Saline soaks or Hydrogen Peroxide, Gel’s.

Other Comfort Tips Avoid tight

footwear/binding clothing/dressings

Hang foot down (at night) Encourage smoking

cessation Avoid trauma

Pain

•Fentanyl pre-dressing change

•Systemic pain relievers

•Gapapentin

•Morphine/gel?

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)

GOAL

Prevent Pain!

Prevent Infection!

Prevent Amputation!

Questions?