by Janet Wolfson PT, CLWT, CWS, CLT-LANA
By Aletha Tippett MD
In my work with wounds, I frequently find the absence of a diagnosis of ischemia, or worse, I find a misdiagnosis. Ischemia is caused by severe obstruction of the arteries, which seriously decreases blood flow. If the arteries are in the heart, you will find a heart attack. If the arteries are in the brain, you will find a stroke. In the skin, you will find a wound.
This is not a rare problem, yet patients are still not diagnosed – why? Twenty percent of all wounds are due to ischemia. Critical limb ischemia affects 1% of everyone older than 50, and double that for those over the age of 70. One out of every four diabetics will have critical limb ischemia. In this country, a lower leg is amputated every six minutes, and 80% of these are from “ischemia.” This is clearly a terrible problem, and wound care providers need to know how to recognize and diagnose it so appropriate treatment can be given.
To recognize ischemia, first look at your patient. Has your patient had a heart attack or stroke? If so, they have ischemia. When you examine the feet and legs, look at the color, temperature, hair distribution, and pulse. Is there decreased hair? Are the legs or feet cool and pale? Can you find a pulse? A misleading sign is dependent rubor — the feet are red when hanging down. A simple bedside test is to elevate the feet; if they turn pale/white this is diagnostic for ischemia. Another easy test is an ankle/brachial index (ABI). Simply check the ratio of ankle systolic blood pressure over brachial systolic blood pressure. Anything less than 0.8 is ischemia. A referral to a vascular surgeon for evaluation is also appropriate.
Does your patient have a wound? Is it on the lateral aspect? Is it “punched out,” painful? Does it have a dry eschar? These are all signs of ischemic ulcers. There are things you do NOT want to do if there is ischemia:
- NO compression: no Unna boot, no TED (Thrombo Embolic Deterrent) hose. It is alarming to me when TED hose is ordered, even when poor circulation is known. Intuitively it should be clear that if circulation is poor, you don’t want to compromise it further with compression.
- NO debridement unless there is active infection.
Treatment for ischemia is possible. Work with your patient to:
- Stop smoking
- Take ASA daily
- Stay as active as possible
- Keep blood pressure under control
- Manage diabetes
- See a vascular surgeon for possible re-vascularization
Treatment for ischemic wounds would be first to restore circulation, if possible. Good wound care would mean Betadine for eschars, and moist dressings for open wounds. Good pain control is mandatory.
If ischemia is not recognized and properly diagnosed, proper treatment of the patient is delayed. If wounds are mistakenly diagnosed as stasis, then compression would be used to the great detriment of the patient. If pressure is diagnosed, the real problem is missed and not treated. Being able to recognize ischemia and properly diagnose it is a great responsibility of wound care provider.
About The Author
Aletha Tippett MD is a family medicine and wound care expert, founder and president of the Hope of Healing Foundation®, family physician, and international speaker on wound care.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.
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