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402 AClJfE CARE HANDBOOK FOR PHYSICAL TIIERAPISTS

from PE include pulmonary hypertension, chronic hypoxemia, and

right congestive heart failure. Refer to Chapter 2 for more details on

ventilation-perfusion mismatches, as well as the respiratory sequelae

(dyspnea, chest pain, hemoptysis, and tachypnea) from PE.6AI

Management of PE consists of prevention of venous thrombosis

formation (see Venous Thrombosis), early detection, and thorough

anticoagulation therapy with standard or low.molecular-weight heparin. Thrombolytic therapy has also been used in patients with PE.

The placement of an inferior vena cava filter is indicated when

patients cannOt be anticoagulated or where there is recurrence of PE

despite anticoagulation.6.41

Clinical Tip

Physical therapy intervention should be discontinued immediately if the signs and symptoms of a PE arise during an examination or treatment session.

Chronic Venolls Insufficiency and Postphlebilic Syndrome

Chronic venous insufficiency and postphlebitic syndrome are similat

disorders that result from venous outflow obstruction, valvular dysfunction from thrombotic destruction of veins, or both. Valvular dysfunction is generally the most significant cause of either disorder.

Within 5 years of sustaining a DVT, approximately 50% of patients

develop signs of these disorders. The hallmark characteristics of both

are the followingl•6.42:

• Chronic swollen limbs

• Thickened (induration), coarse, and brownish skin discoloration in the distal lower extremity

•

Venous stasis ulceration

Management of these disorders may consist of any of the following: leg elevation above the level of the heart two to four times daily for 10-15 minutes; application of proper elastic supports

(knee length preferable); skin hygiene; avoidance of crossing legs,

poorly firring chairs, garrers, and sources of pressure above the

legs (e.g., tight girdles); elastic compression stockings; pneumatic

compression stockings (if the patient needs to remain in bed); exer-

VASCULAR SYSTEM AND HE.MATOLOGY

403

cise to aid muscular pumping of venous blood; surgical ligation of

veins; and wound care to venous ulcers. Refer to Chapter 7 for

more information on wound care.1 •6•42

Clinical Tip

Caution should be taken in providing compressive dressings and elevating the lower extremities of patients who have arterial insufficiency, diabetes mellitus, and congestive heart failure.

Combined Arterial and Venous Disorders

Arteriovenous Malformations

Arteriovenous malformations (AVMs) involve shunting of blood

directly from the artery to the vein, bypassing the capillary bed. The

presence of an arteriovenous fistula in the AVM is usually the cause of

the shunt. The majority of AVMs occurs in the trunk and extremities,

with a certain number of cases also presenting in the cerebrovascular

region.1 3

Signs of AVMs may include the following13:

• Skin color changes (erythema or cyanosis)

• Venous varices

• Edema

• Limb deformity

• Skin ulceration

• Pulse deficit

• Bleeding

•

Ischemic manifestations in involved organ systems

Congenital Vasclliar Malformations

Congenital vascular malformations (CVMs) are rare developmental

abnormalities that may involve all components of the peripheral circulation (i.e., arteries, veins, capillaries, and lymphatics). Signs and symptoms of congenital vascular malformations are similar to those of AVMs, with tissue hypoxia being the mOSt significant clinical finding.

404 AClITE CARE HANDBOOK FOR PHYSICAL TIIERAPISTS

Although congenital vascular malformations can be self-limiting or

incurable, management of certain cases may consist of arteriogram

with embolization, elastic supporrs, and limb elevation.u

Hematologic Disorders

Erythrocytic Disorders

Disorders of RBCs are generally categorized as a decrease or an

increase in the number of RBCs in the circulating blood.

Anemia

Anemia is a decrease in the number of RBCs. Anemia can be described

according to etiology as (1) a decrease in RBC production, (2) abnormal RBC maturation, or (3) an increase in RBC destruction? Anemia can also be described according to morphology based on RBC size or

color.43 RBCs that are of normal size are normocytic; RBCs that are

smaller than normal are microcytic; and RBCs that are larger than normal are macrocytic. RBCs of normal color are normochromic; RBCs of decreased color are microchromic. Some of the most common anemias

are described in this section.

Posthemorrhagic Anemia Posthemorrhagic anemia can occur with

rapid blood loss from traumatic artery severance, aneurysm rupture, or arterial erosion from malignant or ulcerative lesions, or as a result of surgery. Blood loss results in a normocytic, normochromic anemia. The signs and symptoms of posthemorrhagic anemia depend on the amount of blood loss and may include the

following":

• With 20-30% blood volume loss-Dizziness and hypotension

when not at rest in a recumbent position, tachycardia with exertion.

• With 30-40% blood volume loss-Thirst, dyspnea, diaphoresis,

cold and clammy skin, hypotension and tachycardia, decreased

urine output, clouding or loss of consciousness when at reSt in a

recumbent postion.

• With 40-50% blood volume loss-A severe state of shock with

the potential for death ensues.

Management of posthemorrhagic anemia may consist of any of the

following: control of bleeding at the source, intravenous and oral

VASCULAR SYSTEM AND HEMATOLOGy

405

fluid adminisrration, blood and blood product transfusion, and supplemental oxygen.s .• J •• ,

Iron-Deficiency Anemia Iron-deficiency anemia occurs when decreased iron storage in the bone marrow causes the production of microcytic, microchromic RBCs. Iron deficiency can be caused by

chronic blood loss (most commonly from the gastrointestinal rract),

pregnancy, excessive menses, frequent blood donation, rapid body

development, or the malabsorption of iron. Iron deficiency is diagnosed by clinical presentation and serum ferritin laboratory values.

Often, it is asymptomatic if the onset is insidious.46 Signs and

symptoms of iron-deficiency anemia include the following:

• Fatigue, tachycardia, and dyspnea on exertion

• Dizziness

• Headache

• Irritability

• Mouth soreness, difficulty swallowing, and gasrritis (severe

anemia)

• Softening of nails or pale earlobes, palms, and conjunctivae

(severe anemia)

Management of iron-deficiency anem,a may consist of a medical

work-up to identify a possible blood loss site, iron supplementation,

or nutritional counseling.8.43.45.47

Vitamin B12 Anemia Decreased levels of vitamin BI 2 cause the production of macrocytic, normochromic RBCs. Vitamin B12 deficiency is commonly caused by poor absorption of vitamin B'2 from enteritis or iliac disease. Ir is less commonly associared with Crohn's disease and pancrearic insufficiency and is rarely caused by dietary insufficiency.47 Pernicious anemia is a congenital type of vitamin

BIl anemia caused by the absence of inttinsic factor available to

bind to vitamin BIl. In addition to the general presentation of anemia, the signs and symptoms of vitamin B'2 deficiency may include the following:

• Anorexia and diarrhea

• Oral ulceration