3 DVT/PE Flashcards
What are the three aspects of Virchow’s Triad?
- Stasis
- Hypercoagulability
- Vessel wall injury
What is one of the most significant risk factors of thromboembolisms?
PREVIOUS thrombotic event
What are the three most common chronic conditions that are considered risk factors for thromboembolism?
- Malignancy
- Antiphospholipid antibody syndrome
- Myeloproliferative disorders
What are the four most common transient states that are considered risk factors for thromboembolism?
- Surgery
- Trauma
- Immobilization
- Presence of central venous catheter
What are the two most common female-specific factors that are considered risk factors for thromboembolism?
- Pregnancy
- Hormonal contraceptives (BCP)
What are the two most important inherited risk factors (i.e. mutations) associated with thromboembolism?
- Factor V Leiden mutation
- Prothrombin gene mutation
What are the two most significant signs/symptoms of a DVT?
- Swelling
- Larger calf diameter
What constitutes as a high probability for DVT per the Wells criteria?
3+ points
What constitutes as a moderate probability for DVT per the Wells criteria?
1-2 points
What constitutes as a low probability for DVT per the Wells criteria?
0/negative points
If a HIGH probability for DVT is obtained per the Wells criteria, what is the next step in the diagnostic plan?
Order compression ultrasound
If you’re looking for a DVT with compression ultrasound, what is considered a positive finding?
+ for DVT if loss of vein compressibility
If a LOW/MODERATE probability for DVT is obtained per the Wells criteria, what is the next step in the diagnostic plan?
Order D-Dimer test
What is considered a positive D-Dimer test?
If the D-Dimer test is POSITIVE, what is the next step in the diagnostic plan? What if the D-Dimer is NEGATIVE?
> 500 ng/mL
- If positive, order US
- If negative, STOP TESTING
What is the treatment for a proximal DVT? What about for a distal DVT?
- Proximal DVT: ALWAYS anticoagulation therapy
- Distal DVT: consider anticoagulation therapy
What is the goal of anticoagulation therapy?
PREVENT further clot propagation/PE or complications
If a DVT occurs in the upper extremity, which two veins are most commonly occluded?
- Axillary v.
- Subclavian v.
What is the most common cause of an upper extremity DVT?
Catheter placement
How can you differentiate
Superficial Thrombophlebitis from DVT?
Superficial Thrombophlebitis involves dull pain, induration and redness but NO EDEMA
What gender/age is most commonly affected by PEs?
Older men
What are the four classifications of PE that must be considered?
- Hemodynamic stability
- Temporal pattern (acute, subacute, chronic)
- Anatomic location (saddle, lobar, segmental, subsegmental)
- Symptomatic vs. Asymptomatic
What is considered hemodynamically unstable with a PE (think BP changes)?
Unstable if systolic BP <90 mmHg or drop in systolic BP of 40+ mmHg from baseline for 15+ minutes
What two symptoms are most commonly associated with a PE?
- SOB/dyspnea
- Pleuritic chest pain
If a PE is hemodynamically unstable, what is the next step in the diagnostic plan?
Echocardiography (other definitive imaging is unsafe)
If a PE is hemodynamically stable, what is the next step in the diagnostic plan (4)?
Combine clinical with Wells for PE, D-Dimer test, and CTPA
If a HIGH probability for PE is obtained per the Wells criteria, what is the next step in the diagnostic plan?
Order CTPA
If a LOW/MODERATE probability for PE is obtained per the Wells criteria, what is the next step in the diagnostic plan?
Apply PERC (list of 8 PE rule out criteria)
What is considered a positive PERC test?
If the PERC test is POSITIVE, what is the next step in the diagnostic plan? What if PERC is NEGATIVE?
PERC: ALL 8 criteria are negative
- If positive, order D-Dimer
- If negative, STOP TESTING
If a CTPA cannot be obtained to rule out PE, what is an alternative test that can be considered?
Ventilation perfusion scan (V/Q)
What is the treatment for a PE?
ALWAYS anticoagulation therapy
Which three anticoagulation therapy options are preferred to IV unfractionated Heparin to treat thromboembolisms?
- SubQ Factor Xa inhibitor (Fondaparinux)
- Oral Factor Xa inhibitor
- SubQ Lovenox
What three conditions for thromboembolisms would warrant treatment with IV unfractionated Heparin?
- Severe renal failure
- Hemodynamically unstable PE
- Massive iliofemoral DVT
For which two population groups is Lovenox (LMWH) considered the DOC to treat thromboembolisms?
- Pregnant
- Active cancer
The drugs that end in “aban” are from what type of inhibitor group to treat thromboembolisms? Are these drugs oral or IV?
i.e. Rivaroxaban (Xarelto), Apixaban (Eliquis), Edoxaban, Betrixaban
Factor Xa inhibitors
- The “aban” drugs are all oral
What is the one IV Factor Xa inhibitor?
Fondaparinux
What is the one Direct Thrombin inhibitor? Is this drug oral or IV?
Dabigatran (Pradaxa)
- Oral
What is the most common long-term anticoagulation therapy used to treat thromboembolisms?
Warfarin
Why might a patient/provider consider use of an oral Factor Xa inhibitors OR oral thrombin inhibitors instead of Warfarin?
To avoid the burden of PT/INR monitoring (as with Warfarin)
What is the recommended duration of anticoagulation treatment for a first episode thromboembolism?
Minimum of 3 months for 1st episode
What is the recommended duration of anticoagulation treatment for a provoked thromboembolism? What is an example of a provoked VTE?
3 months
- Could occur with surgery
What is the recommended duration of anticoagulation treatment for an unprovoked thromboembolism?
LONGER (6-12 months)
What four conditions would warrant lifelong/indefinite anticoagulation treatment for a thromboembolism?
- 1st episode of unprovoked proximal PE/symptomatic PE
- Recurrent episodes of unprovoked proximal PE/symptomatic PE
- Underlying thrombophilia
- Active malignancy
What is the most common anticoagulation reversal therapy we discussed? Why would you want to use reversal therapy?
aPCC
- Use if blood too thin OR bleeding out
What are three adjunctive treatment options to anticoagulation?
- Thrombolytics
- IVC filter
- Thrombectomy/Embolectomy
What is another name for Thrombolytics (describes their function)?
Clot buster
What two adjunctive treatment options to anticoagulation should be considered for a hemodynamically unstable PE patient?
- Thrombolytics
- Thrombectomy/Embolectomy
What four minimum criteria must be met in order for a patient to be considered for discharge home (rather than admission) for thromboembolisms?
- Pain controlled
- Compliant/reliable
- Capable of administering injections if subQ tx
- Able to pay for injectable agents while transitioning to oral Warfarin
What four VTE prophylactic measures can be used (prevention is key…)?
- Intermittent pneumatic compression (IPCs)
- Thromboembolic deterrent (TED)
- Graduated compression stockings (GCS)
- EARLY ambulation
