Causes of peripheral oedema (cardio)(vasc)

Peripheral oedema can be pitting or non-pitting.

The main cause of non-pitting peripheral oedema is lymphoedema in which sufferers typically have a congenital malformation of the lymphatic vessles in the limb(s) leading to accumulation of lymph in the affected parts of the body. This is non-pitting and is woody hard.

In pitting peripheral oedema, the problem is caused by an increase in hydrostatic pressure inside the blood vessles or a decrease in oncotic pressure or both. Therefore the causes can be:

1. Renal -- renal failure, nephrotic syndrome etc leading to a decrease in oncotic pressure. (of course severe liver failure would lead to a decrease in protein content in the plasma too) Swelling tends ot be symmetrical except in situations like superimposed varicosity.
2. Cardial
3. Venous

CardialMainly cardiac failure. Also hypertension.
Cardiomyopathy, valvular disease, pericardial disease.

Oedema tends to be symmetrical.

VenousObstruction due to (moving up the venous tree):

1. DVT - asymmetrical swelling unless bilateral DVT
   
2. Pelvic mass - asymmetrical swelling possible
   
3. IVC obstruction e.g. thrombus
4. Right atrium - fibrillation/flutter, tricuspid regurg
   
5. Tricuspid stenosis
6. Cardiomyopathy
7. Pulmonary valve disease
8. Pulmonary tree disease e.g. PE, Pulm hypertension
9. Left atrial flutter/fibrillation
10. Mitral valva disease
11. LV dysfunction
12. Aortic valve disease
13. Pericardial disease - constriction/tamponade

(*4 to 13 not strictly speaking venous problems, but they show a logical pattern of thinking when considering causes to a problem. In this case, the anatomical model is used.)

Mid-diatolic murmurs (cardio)

Typically a feature of mitral stenosis (Fa---tah-tah-rrrrrrrrrr) but can also be one of the following three eponymous murmurs:

1. Carrey-Coombes
Acute rheumatic fever leads to thickening of the mitral valves and therefore give a middiastolic murmur. This is strictly speaking not a mitral stenosis (as there is no narrowing) and is thus called a Carrey-Coombes murmur.

2. Austin-Flint
In aortic incompetence, the pressure from the backlash of blood from the aorta prevents the mitral valve from opening and creates a functional block. This therefore gives a middiastolic murmur termed an Austin-Flint murmur, best heard over the left sternal edge.

3. Graham-Still
Similar to Austin-Flint, but problem resides in the right heart.

To increase vagal tone (cardio)

There are 3 easy ways to increase vagal tone, but only one is recommended:

1. Valsaval maneouvre -- basically increasing the intrathoracic pressure by blowing into a tightly pinched nose and a closed mouth. Always tell patients to use this one ONLY.

2. Carotid massage -- massaing the carotid bodies trigger off the baroreflex which increases the vagal tone and lowers cardiac output. Not recommended as A) could dislodge atheroma. B)could lead to severe bradycardia or even asystole in especially the elderly.

3. Eyeball massage -- Not recommended as there is risk of retinal detachment.