10 - Venous Thromboembolism Flashcards
80% of PE’s start where?
In the legs
Blood clot occurs when:
Coagulation exceeds the removal by fibrinolysis
Provoked VTE’s
Recent surgery Trauma Limb or body immobility Active CA Infection Impeded venous flow Chronic dz Estrogen use Pregnancy > 50 yrs old
Does S1Q3T3 mean PE?
No, just heart strain
Survivors of PE go on to develop:
Heart dysfunction
Limb immobility risk of DVT:
From least to most: Elbow Shoulder Ankle Knee Hip
Number one risk factor for PE:
Stasis
Risk factors
Age Obesity Pregnancy Post-partum Prior VTE Solid CA’s Hematoligic CA’s Imobility Long distance travel Smoking CHF Stroke
Hallmark of PE is:
Dyspnea unexplained by auscultatory findings, ECG changes, or clear alternative diagnosis on CXR
Classis PE pain
In the thorax between the clavilces and the costal margin that increases with cough or breathing
PE findings with PE:
Tachycardia Tachypnea Low SpO2 Mild fever Wheezing, rales, possible
Pts with DVT c/o:
Extremity pain, swelling, cramping
What sign can calf vein thrombosis cause?
Homan’s sign - calf pain elicited by passive foot dorsiflexion
What is phlegmasia alba dolens?
A swollen, painful, pale or white limb with a proximal venous thrombosis
Does the presence of hypoxemia or dyspnea with clear lungs on exam and imaging confirm PE?
No, just SUGGESTS it
MC ECG findings for PE?
Nonspecific ST- and T-wave changes
If PE is bad enough, what changes will ECG show?
T-wave inversion in V1-V4
Incomplete or complete RBBB
Classic but uncommon -> S1Q3T3
Well’s score
Slides 37 / 38
Know this
D-dimer - what’s the deal with it?
Better to order if you don’t think they have a PE
Cuz you get that negative and you’re good
What is the PERC?
Eliminates the D-dimer
Useful for assessment of likelihood of PE
Gotta be low likelihood and under 50yrs
The rest is on slide 36
PERC positive?
Get the d-dimer
Wells and PERC - what do i need to know?
Not how to calculate - just what to do with the numbers
Problems with d-dimer?
Many false positives and false negatives
Wells scores
> 6 points = high risk
2-6 points - moderate risk
< 2 points = low risk
Low - go home
Mod / high - CT scan
Most common imaging modality for PE?
Chest CT angiography
Identifies the presence and location of the clot
Also can pick up other problems if its not a PE
Can’t get the CT?
V/Q scan - nuclear med scan
Alternate chest imaging for preggos
What used to be the gold standard for imaging (before CT?)
Direct pulmonary angiography
Imaging test of choice for DVT?
Ultrasound
US for DVT’s?
You should be able to compress with the transducer
If you can’t, its bc there’s a clot preventing it
Low pre-test probability for DVT?
Get the d-dimer
If neg, youre good
If pos, get the US
Hight pre-test pos for DVT?
Get the US
US pos, txt the DVT
US neg, get the d-dimer
Neg d-dimer, youre good
Pos d-dimer, do US again in a week
The two most common options for DVT txt are:
UFH or LMWH
That’s the first thing we give, to stabilize the clot (keep it from getting bigger)
In addition the starting UFH/LMWH:
Remove constrictive clothing, cast, or dressing
Arrange for consultant-delivered catheter-directed thrombolysis
If pt has thrombophlebitis
NSAIDs
What is the only newer oral med approved for both DVT and PE?
Rivaroxaban (Xarelto)
Massive PE presentation
SBP < 90 for >15 mins
Possible AMS
Or <100 with HTN
Or
> 40% reduction in baseline SBP
Consider fibrinolysis in which PE pts
Cardiac arrest
HOTN
Respiratory failure
Evidence of r-sided heart strain echocardiography
In young patients with a large, proximal PE, what’s another option?
Surgical embolectomy
Risky
Why is post-partum a high-risk for DVT/PE period?
Recent trauma
High estrogen
Stasis
Hey girl, are you a pulmonary embolism?
Cause you make me breathless
