Peripheral blood vessel examination

2021-01-26 12:00 AM

Learn to examine peripheral blood vessels or limb vessels mainly to know how to examine and detect the symptoms of peripheral vascular diseases.

Concept

Learning to examine the peripheral blood vessels (or chi vessels) mainly to know how to examine and detect the symptoms of peripheral vascular diseases. But peripheral vascular pathology is a very broad field of specialization, covering many different types of diseases such as diseases of the arterial system, of the venous system, of the lymphatic system, congenital diseases, acquired diseases, diseases of the apical circulation… Therefore, their symptoms are very diverse and complex.

Clinically, peripheral vascular disease can be divided into two main groups:

Group of vascular diseases: Mostly includes diseases of the blood vessels themselves, very complex, of a specialized nature, with no or little of emergency nature. For example, diseases: arteriosclerosis, atherosclerosis, varicose veins ...

Group of acute vascular lesions: Most occur on normal blood vessels, not too complicated, especially of a very emergency and general nature. In which: injury, injury and acute blockage of the limb artery are the most common lesions.

Epidemiology of acute peripheral vascular injury: Account for over 85% of emergency trauma - vascular injury. At Viet Duc hospital, peripheral vascular emergency care accounts for 2-3% of surgical emergencies.

Some general principles in the physical examination of peripheral blood vessels:

2-sided comparison examination.

Compare the upper and lower extremities.

Body examination: Since many vascular diseases of the limbs are systemic diseases with damage to the vessels in many places (such as atherosclerosis), the manifestation of the extremities is the result of other damage (occlusion of the arteries due to thrombosis in the heart) and have limb vascular diseases affecting the whole body (dynamic - late venous - affects the heart)

Note also to examine diseases that are risk factors closely related to some blood vessel diseases such as high blood pressure, diabetes, smoking ...

Symptom learning

Acute limb artery lesions are common.

Concept

There are three common causes of acute limb artery damage: an injury, an artery injury, and an acute occlusion of the arteries.

Since the arterial circulation to the peripheral blood was suddenly cut off, all three lesions have a very important general clinical feature, "Peripheral ischemic syndrome".

Diagnosis of these acute lesions is mainly based on clinical examination. They are the number 1 priority in surgery and should be treated as early as possible, preferably within 6 hours of the injury. If left late, it can cause serious consequences and sequelae such as amputation, kidney failure, and even death.

Pathology

In arterial wounds:

Cause: Usually by knives, sharp objects, foreign bodies, shavings or fire.

Arterial damage:

Lateral wounds: Often cause bleeding a lot, it is difficult to stop bleeding with normal pressure if injured in a superficial artery (arm artery, rotating artery - pillar, common thigh). If the wound is small, usually does not cause acute limb anaemia but later progresses to pseudo-artery or catheterization.

The wound has left the circuit: Because the broken end of the circuit often shrinks into the soft tissue, it is easier to stop bleeding with a pressure bandage. Definitely cause limb acute anaemia.

Soft tissue damage and auxiliary circulation: Depending on the agent and the mechanism of the wound, if there is a large soft tissue wound, it will greatly affect the auxiliary circulation system.

In arterial trauma:

Cause: Due to the direct impact on the artery (rare) or lack of cockroaches due to displacement fracture puncture the vessel or pulls the vessel causing trauma (common). Common in traffic accidents and labour.

Arterial damage mainly encountered the following:

Crush a whole circuit segment (usually 2 - 5 cm), causing breakage or stick together by a part of the vessel wall. This injury is common.

Crushing part or all of the circumference of the vascular wall on a short segment (usually <2 cm), causing local thromboembolism. On the appearance of the stamping circuit, the only discolouration is purple, firm and non-stamping, the size of the circuit is almost normal. The reality is quite common.

Arterial spasm: Usually due to fracture or displacement, the vessel is stretched, causing spasm. Can cause acute - subacute anaemia. Common in the brachial convex fracture.

Endometriosis: It is rare but very dangerous because it is easy to miss. Because at first, the vessel is still circulating normally, then a thrombus formed at the lesion will cause a local embolism or drift down causing embolism in the downstream side.

Soft tissue and auxiliary circulatory lesions: Software is often crushed - torn due to direct trauma and the broken ends of bone poke into the auxiliary circulatory system.

Fracture sites often cause artery injuries:

Upper limb: Fracture of the arm bulge, injury to the elbow area.

Lower extremities: Broken tibial plateau, broken femoral convex, lower femoral 1/3 fracture, 1/3 fracture above the tibial plateau

 In acute chi artery occlusion:

Cause: Because foreign bodies from the disease foci in the upstream are removed and drifted down, causing the limb artery. The foreign body is usually a thrombus, flakes (in Osler), in addition, it may be a tumour piece, atheroma ...

Etiology:

Heart disease: most common in Vietnam, especially mitral valve disease, complete arrhythmia, often forming a blood clot in the atrium - left atrium.

Infectious endocarditis (Osler): Creates nodules on the mitral valve and aorta, which are increasingly encountered due to the high rate of drug injection.

Left atrial mucous tumour: Uncommon

Thromboembolism: Rarely.

Atherosclerosis: Very rare.

Commonly blocked sites:

The primary occlusion point always begins at the junctions of major arteries, for example:

Upper limb: Rotating divider - a pillar of the arm artery ...

Lower extremities: 3 root pots, inner pot - outer pot, shallow thigh-deep thigh, 3 coronary arteries.

Later, the thrombus continues to gradually spread from the primary to the lower clogged position, clogging the smaller artery branches downstream.

Common joint injuries: In addition to fractures, bruising - soft tissue damage, damage to other organs, diseases ... are factors that aggravate blood vessel damage. It should be noted that two lesions of local coordination are common in arterial wounds, which are venous and nerve wounds depending on arterial action. 

Pathophysiology

Since acute damage causes a sudden cessation of blood supply to peripheral circulation through the main arteries, it only relies on the accessory circulatory system. However, because it happens suddenly, the auxiliary circulatory system has not developed enough to replace the main blood supply. So will quickly lead to acute anaemia of the peripheral organs.

Over time, the anaemia of the organization worsens, causing partial destruction and then the whole limb leads to limb necrosis, gradually spreading from the tip to the base of the limb. People often divide this anaemia into 2 phases:

Stage of reversible anaemia: That is, in this period, if promptly re-treating blood vessel circulation, the limb will be completely restored in terms of blood supply. This is usually counted within 6 hours of the injury.

Stage of irreversible anaemia: Progress from partial to complete irreversible, due to the gradual necrosis phenomenon of peripheral organization. When this stage is over, although the limb has not been completely necrotic, if treatment is repeated, the blood vessel circulation, the lower limb only partially recovers in blood supply and function. When chi is completely necrotic, there are no longer indications for chi conservation. In clinical practice, the mould is usually taken after 6 hours to begin to switch to irreversible anaemia, the severity worsens over time and usually, after 24 hours leads to incomplete recovery.

In fact, the progression of stages of anaemia is influenced by a number of factors, such as:

Arterial injury location: If the injury is under a large lateral arm, the recovery time of anaemia may be longer, due to the better blood supply through the sub circulation (lower arm artery under the posterior part of the arm)., shallow femoral artery).

Soft tissue damage: If you have more damage, the anaemia will be worse because the circulatory system is also damaged.

The patient's status: If there is hemodynamic disorder, the anaemia progresses faster due to decreased perfusion through the sub-circulatory system. 

Clinical symptoms

The most important clinical symptom is "Peripheral Acute Anemia Syndrome", so it is important to respect a principle of clinical examination: always compare the chi with benign limbs, and pay attention to the symptoms. anaemia changes and evolves over time.

Mechanical symptoms:

Manifestations of acute limb anaemia:

The stage of reversible anaemia: Numbness, decreased sensation, decreased apical movement after an injury. Sometimes the sick person even senses that the injured limb is cooler than the healthy limb.

Severe anaemia stage: Chest pain and then leads to complete loss of movement and feeling towards the extremities.

Manifestations of the type of lesion:

In arterial wounds: After being injured, there is a lot of bleeding through the wound, typically spitting blood in a jet. Pain at the wound site.

In arterial trauma: Very painful, swelling of the injured area, loss of limb movement (due to fracture).

In acute arterial occlusion: Often the disease starts with a stroke that causes a sudden reduction or loss of active limb movement.

In addition, through questioning, it is necessary to learn more about the mechanism, the agent that causes the injury, and the history of cardiovascular disease.

 Systemic symptoms:

Overall: Little change in day one. In the case of limb necrosis due to anaemia so that it is too late to cause poisoning, drowsiness, struggles, rapid pulse, drop in blood pressure, pale skin mucosa, low urination ...

In arterial wounds: Anemia can be seen if there is a lot of blood loss through the wound, such as blue skin, pale mucosa, rapid pulse, even blood loss shock that causes hypotension, cold, sweaty limbs, dazed ...

In arterial trauma: If bone damage, local soft tissue is too severe, or complex coordination damage of other organs can be seen, blood loss shock, trauma shock such as drowsiness, blue skin pale, pale mucosa, tachycardia, low blood pressure, cold limbs, sweating ...

In acute arterial occlusion: Systemic manifestations of diseases such as high blood pressure, heart failure, Osler ...

Symptoms at the site of damage vessels:

In arterial wounds:

There are 2 possibilities:

Seeing that there is a soft wound lying on the path of the blood vessel, the bleeding has stopped due to first aid stopping the bleeding (using a pressure bandage, stitching the wound ...). There is a hematoma around the wound, typically palpable by the heartbeat. In fact, most of them have this form.

Seeing a soft wound lying on the way of blood vessels, whether or not having first aid has stopped bleeding, but still bleeding a lot, red blood through the wound, typically sprayed into a jet. This form is rarely seen in clinical practice.

In arterial trauma:

Symptoms of fracture such as swelling, swelling, deformation, axis deviation ... if it is indirect injury due to fracture.

Signs of swelling, bruising, hematoma or soft crushing on the path of the blood vessel if in the form of direct injury.

Symptoms of the lower limb lesions:

Mainly "Acute anaemia syndrome":

Colour and temperature of extremities: Pale, cold skin.

Peripheral angioplasty saw much reduction or loss, fingertip vasomotor decreased.

Sensory disorders: The burning sensation subsides and then disappears completely, going from the tip of the limb to the base of the limb.

Movement disorders: Active movement gradually decreases, then completely loses, gradually going from the top of the limb to the base of the limb.

Severe soft software anaemia: The muscles (such as calves) are swollen and painful when the pain increases.

Severe irreversible anaemia: Appears blisters, joints are stiffened like cadaveric joints, then black purple patches scattered across the skin, then a black-purple extremities necrosis.

Distribution of symptoms according to the stage of anaemia:

The above symptoms get worse and evolve over time. To help assess the degree of anaemia in a clinical setting, the following symptoms can be distributed:

The stage of anaemia with recovery (usually <6 hours): The limbs are pale, lose pulse, decreased sensation and movement of the extremities.

The phase of partially irreversible anaemia (usually> 6 h): Appearance of more signs of swelling - muscle pain, loss of sensation and movement of the extremities.

The incomplete recovery period of anaemia (usually after 24 hours): Additional signs of severe irreversible anaemia.

In addition, when examining the lower extremities, it is important to pay attention to detect additional signs of damage to the veins and coordination, especially common in arterial wounds.

Vein damage: Usually manifested in lower extremities. In addition to the above symptoms, there are also signs, pale limbs but slightly purple, and shallow veins widening.

Neurological damage: Common medial and cylindrical nerves, with symptoms of loss of sensation and motor paralysis of the corresponding nerve governing areas: eg, signs of paralysis, paralysis of muscles (monkey hand) of the median nerve, the drooping hand of the rotational nerve, accompanied by signs of loss of sensation in the median nerve or the column in the hand ...

Clinical features of several other acute peripheral vascular lesions

Pure venous injury without artery damage:

The site of the wound is also usually located in the path of the blood vessel.

After the injury, black blood flowed through the wound, easy to handle with a pressure bandage.

There was no sign of peripheral anaemia.

The veins are shallow, slightly purple in colour 

Limb-risk aneurysm: Common in the traumatic aneurysm. Includes signs of aneurysms (item 3) - pain in the bulging area.

Broken chi: Also common in pseudo-artery aneurysms resulting from trauma or injection. There are 2 clinical possibilities:

Subcutaneous rupture: Common in traumatic pseudo-bulging include:

Aneurysm threatens to rupture.

Pain is suddenly intensely severe, with reduced or loss of limb movement.

Losing the boundary of the bulge, the entire limb is swollen, stiff, the skin is inflamed and red so it is easy to mistake it for purulent inflammation.

Weak peripheral vessels, but unclear signs of anaemia.

Superficial veins ...

Broken Out: Common in pseudomembranous injection.

History of injection.

Signs of bulging arteries threatening to rupture.

A lot of bleeding is usually through the puncture site on the bulge.

Weak or absent peripheral vessels, but no limb anaemia. 

Thrombophlebitis:

Usually develops in the lower extremities, in subjects with high risk factors such as:

History of thrombophlebitis.

Have varicose veins

After the injury, surgery must lie down for a long time.

After lower limb injury.

Pregnant, postpartum ...

The main symptoms:

Chi swollen, gradually spread to the base of the limb.

Pain, red inflammation, swelling of the entire limb.

There may be an infection syndrome.

Varicose veins are shallow, tight, clear, not flat.

There is no arterial anaemia. 

Symptoms of some common vascular diseases

Concept

Although it includes many different types of pathology, most vascular disease is non-emergency. Complicated diagnosis and treatment.

Can be primary diseases such as: arterial swelling, dynamic - venous, congenital, malformed blood vessels, blood tumors ...

It can be secondary to another disease or trauma such as stenosis, atherosclerosis, arterial catheterization, trauma to the artery ...

Can be divided into diseases of the arteries, diseases of the venous system.

Clinical symptoms of some common diseases

Lower limb chronic anemia syndrome: Due to atherosclerosis causes narrowing of the arteries: pain intermittent, fatigue during movement, cramps, leg numbness, vasculature, skin dystrophy, and ulceration due to oliguria.

Aneurysm: The swelling can be caused by disease (real swelling, seen in the elderly, atherosclerosis) or trauma, injection (fake swelling).

Main symptoms: The tumor is located on the path of the blood vessel, pedal - dilated with the heartbeat, can be heard systolic blowing, compressing the pulse above, the small tumor loses the above signs.

Vein catheterization due to trauma: History of trauma, signs of limb dystrophy (dry skin, thickening, ulcers, necrosis, bleeding), continuous blowing of the wound area, palpation of tremors, shallow veins stretch ...

Varicose leg veins: Common disease in the elderly and women, due to the opening of venous valves leading to stasis and varicose veins.

Main symptoms:

Superficial supernatant veins zigzagging under the skin (around the vein system that is enlarged and extensively) in an upright position, sometimes clumping, slight edema of the feet and ankles, skin nodules,

Signs of reverse wave (Schwartz maneuver): Touching one finger on a large vein, patting the visible vein above with another finger, feel like a wave on the first finger, manifest of venous valve regurgitation.

Trendelenburg test: Let the patient lie with their legs up high, swipe from the ankle to the thigh, then place the garo lightly at the base of the thigh, ask the braid to stand and release the garo, observe that the subcutaneous vein swells, if time <30 second, i.e., the valve is open and the superficial veins dilate gradually from top to bottom. 

The image exploration

Imaging is the main subclinical method for the diagnosis of peripheral vascular lesions, as well as general vascular diseases. However, in practice, these probes are mainly used for pubic artery diseases, but in the emergency, they are used only in a few cases that are difficult to diagnose clinically. Includes the following exploration:

Vascular Doppler: The probe does not bleed, very popular today. There are many types such as: expressed by sound, recorded on paper or pictures, most modern is color Doppler.

Allows to see the images of embolism, stenosis, aneurysm, thrombosis, varicose and cleft palate, assess the level of damage and many other parameters ...

Angiogram: Is a bleeding probe, including 2 types of imaging is common and digitized. Shows images of embolism, stenosis, auxiliary circulation ...

Large-cut and magnetic resonance imaging: Quite prevalent today. There are many types of scan: normal, pumped and scanned. Or used in aortic balloon, thoracic aorta and some other diseases. Less used in peripheral vascular disease.

Venous scan: Currently used only in a few diseases such as some thrombophlebitis, upper aortic imaging in mediastinal tumors.