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Medicine Y3 TCD 1-12 > 6. Venous Thromboembolism aka VTE (DVT and PE) > Flashcards

6. Venous Thromboembolism aka VTE (DVT and PE) Flashcards

1
Q

what does DVT mean

A

deep vein thrombosis

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2
Q

what does PE mean

A

pulmonary embolism

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3
Q

what are both DVT and PE forms of

A

VTE - venous thromboembolism

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4
Q

what is a thrombus

A

a blood clot within the body

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5
Q

what is an embolus

A

material which is transported in the blood stream and lodges in a blood vessel at a different site

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6
Q

where do most VTE develop and why

A

in the deep veins of the leg

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7
Q

what disease makes VTE more likely

A

varicose veins

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8
Q

what 3 things make up the Virchow’s triad

A

stasis of blood flow
endothelial injury
hyper-coagulability

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9
Q

give some reasons why patients may have the following elements of the virchows triad

  1. stasis of blood flow
  2. endothelial injury
  3. hyper-coagulability
A
  1. they are immobile ie in bed
  2. acute phase reactant proteins (that increase due to inflammation) like fibrinogen, factor VIII and vWF
  3. obvious is there is a leg or pelvic injury or if need plaster cast. not that stasis itself will cause some endothelial injury
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10
Q

What mechanical interventions can prevent VTE

A

anti-embolism stockings (AES)

intermittent pneumatic compression sleeves (IPC)

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11
Q

name 3 pharmacological interventions that can prevent VTE

A

low lose low molecular weight heparin (SC) - LMWH
low dose unfractionated heparin (IV) - UFH
direct anti-Xa and anti-thrombin drugs (O)- DOAC

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12
Q

what negative effect could you get form heparin therapy

A

herpain induced thrombocytopenia and thrombosis (HITT)

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13
Q

in the prevention of VTE why would you not use warfarin

A

the intensity of anticoagulation is less predictable and erratic and bleeding risk is much high than that with heparin or DOAC

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14
Q

investigation before treatment should only be done in what time frame for

  1. PE
  2. DVT
A

if investigation can be done within 1 hour for PE or 4 hours for DVT

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15
Q

particularly post-op why is it preferred to use UFH (un fractionated heparin)

A

can be immediately reversed (protamine sulphate) or just stopped if post-op bleeding or redo surgery is required

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16
Q

why does heparin need to be continued when starting oral warfarin

A

it can take 48-72 hours to reach its therapeutic range and at that point, heparin can be stopped

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17
Q

Name some risk factors for VTE

A 
immobility
recent surgery 
long haul flight s
pregnancy 
hormone replacement therapy with oestrogen (combined oral contraceptive pill and hormone replacement therapy)
malignancy 
polycythaemia 
systemic lupus erythematosus 
thrombophiila
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18
Q

what condition can predispose patients to developing blood clots

A

antiphospholipid syndrome

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19
Q

what is the main contraindication for compression stockings

A

peripheral arterial disease

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20
Q

What is the usual presentation of a DVT

A

almost always unilateral

  • calf or leg swelling
  • dilated superficial veins
  • tenderness to the calf (particularly over the site of the deep veins
  • odema
  • colour changes to the leg
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21
Q

how do you examine for leg swelling

A

measure the circumference of the calf about 10cm below the trivial tuberosity
more than 3cm difference between the calves is significant

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22
Q

what score predicts the risk of a patient presenting. with symptoms actually having a DVT or PE

A

the Wells score

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23
Q

what single blood test can differentiate between a patients having VTE or not

A

d-dimer

can exclude VTE where there is a low suspicion

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24
Q

as well as being raised in VTE, what other conditions cause a raised d-dimer

A 
pneumonia
malignancy 
heart failure 
surgery 
pregnancy
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25
Q

what investigation can diagnose a DVT

A

ultrasound doppler of the leg and positive d-dimer

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26
Q

how can a PE be diagnosed

A

CT pulmonary angiogram (CTPA)

ventilation perfusion scan (VQ) scan

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27
Q

what is the initial management of a VTE and when should it be started

A

treatment dose low molecular weight heparin (LMWH)
should be started immediately before confirming the diagnosis in patients where DVT or PE is suspected and there is a delay in scan

28
Q

give some common examples of LMWH

A

enoxaparin
dalteparin
tinzaparin

29
Q

what are the options for switching to long term anticoagulation in VTE

A

warfarin
NOAC
LMWH

30
Q

What is the target INR for warfarin and what does a raised INR mean

A

2-3

means blood is taking longer to clot outside your body

31
Q

what is the long term preferred 1st line anticoag for pregnancy or cancer

A

LMWH

32
Q

How long should anticoagulation be continued for;

  • if there is an obvious reversible case
  • if the cause is unclear, there is recurrent VTE or there is an irreversible underlying cause such as thrombophiliia
  • in active cancer
A
  • 3 months
  • beyond 3 months (usually 6 in practice)
  • 6 months
33
Q

if patients have their first VTE without a clear cause then NICE recommend to screen for cancer
Q: how do you do this

A
  • history and examination
  • CXR
  • bloods ( FBC, calcium and LFT)
  • urine dipstick
  • CT AP in pt over 40
  • mammogram in women over 40
34
Q

if patients have their first VTE without a clear cause then what else do you want to test for apart from cancer screening

A

antiphospholipid syndrome

- check this by checking for antiphospholipid antibodies

35
Q

What is budd-chiari syndrome and how does it classically present

A

a blot clot (thrombosis) develops in the hepatic vein blocking the outflow of blood
- associated with hyper-coagulable states and causes acute hepatitis

  • abdo pain, hepatomegaly and ascites
36
Q

Describe the flow of a blood clot to the lungs

A

from blood vessel in the body, to the right atrium, passes out of the right ventricle and into the pulmonary arteries where it lodges

37
Q

what are the physical signs of PE

A

increased RR
tachyarrhythmias (comment is sinus tachycardia but may have atrial fibrillation)
possibly signs of DVT

38
Q

what is a massive PE

A

large clot that lodges in the right side of the heart or in both pulmonary arteries (saddle embolus)

39
Q

how does a massive PE classically present

A

syncope (LOC) as well as the other symptoms of PE

  • increased RR
  • tachyarrhythmias
  • signs of DVT
40
Q

how is massive PE clinically defined

A

the presence of arterial hypotension (systolic BP less than 100) or cariogenic shock/cardiac arrest
- medical emergency and requires urgent thrombolysis

41
Q

What are the risk factors for DVT

A
  • active cancer (includes treatment within the past 6 months)
  • FH of DVT
  • immobility for 3 days or more, or major surgery within 12 weeks
  • Age especially over 60s
  • previous DVT
  • note that it is not related to gender
42
Q

What is PERC and how is it used

A

Pulmonary embolism rule out criteria score

- 8 clinical criteria

43
Q

Investigating PE:

why would you wan to do a FBC

A

useful prior to anticoagulation and to rule out infection

44
Q

Investigating PE:

why would you wan to do a LFT

A

to check before starting anti-coat therapy

45
Q

Investigating PE:

why would you wan to do an ECG

A

to asses the rhythm in any tachycardia patient

46
Q

on and ECG what are you looking for which would suggest the patient has a massive PE

A

In big PE, may show signs of R heart strain (S wave in I, Q waves in III, T waves in III)

47
Q

What is the investigation of choice in most people with a high probability of PE, or low probability and raised D-dimer

A

CTPA and if not pregnant then a V/Q scan

48
Q

in what scenario would you want to do a CRP

A

if an infection is indicated

49
Q

as well as LFT what other blood test would you want before starting on anti-coag treatment

A

U and E

50
Q

How would you exclude a pneumothorax

A

CXR

51
Q

how would you investigate for a massive PE with haemodynamic compromise to look for RHF

A

echocardiogram

52
Q

true or false;

- a d-dimer is indicated before a CTPA if someone has a high probability of PE

A

false

should do CTPA first if there is a high suspicion

53
Q

what can be safely excluded if D-dimer result is negative

A

VTE, PE and DVT

54
Q

in someone with PE they may get type 1 respiratory failure. What is this

A

low oxygen and normal CO2
- there is a V/Q mismatch as parts of her lung are getting air into them, but have no blood flow for gas exchange as they have PE

55
Q

in patients with PE why would they have respiratory alkalosis

A

high RR so they are blowing off her CO2

56
Q

Give some examples of LMWH and give the option to patients that have personal, religious or cultural preference s

A

most LMWH are made of porcine
dalteparin and enoxaparin are the main two
Fondaparinux is the synthetic alternative

57
Q

name some common DOAC

A 
Apixaban 
rivaroxaban 
( other examples are dabigatran and edoxaban)
58
Q

in which patients. would DOAC be contraindicated in

A

severe renal or hectic impairment or if there is a view to starting warfarin

59
Q

what are the common effects of DOAC

A

bleeding, bruising, nausea and anaemia

60
Q

in what specific scenarios is rivaroxaban contraindicated

A

if you are pregnant
hepatic impairment
renal disease is eGFR of less than 15 (warfarin would be safer if less than 30)

61
Q

What is the first line treatment for PE

A

Apixaban or rivaroxaban

62
Q

if Apixaban or rivaroxaban aren’t suitable then LMWH for at least 5 days followed by what drug

A

dabigatran or edoxaban

63
Q

Name some common respiratory causes that can cause similar symptoms to a PE

A

pneumothorax
Pneumonia
Acute bronchitis
acute. exacerbation of asthma

64
Q

name some common cardiac cause that can cause similar symptoms to a PE

A

ACS
congestive heart failure
pericarditis
unstable angina

65
Q

Name some other differentials that can cause similar symptoms to a PE

A 
musculoskeletal chest pain 
GORD
vasovagal syncope
postural hypotension 
panic disorder

Medicine Y3 TCD 1-12 (30 decks)

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