7- DVT Flashcards
what is the single greatest contributor to death in this country
smoking
The three leading specific causes of smoking-attributable death were
lung cancer
ischemic heart disease
COPD
what is the single largest risk factor for cardiovascular mortality in the US.
HTN- decreases life by 20 years
differential for unilateral leg swelling
cellulitis, lymphedema, or DVT
differential for bilateral leg swelling
venous insufficiency or peripheral artery disease
lymphedema
painless, but patients may experience a chronic dull, heavy sensation in the leg. starts in foot–>goes up
In the early stages of lymphedema, the edema is soft and pits easily with pressure.
In the chronic stages, the limb has a woody texture and the tissues become indurated and fibrotic.
cellulitis
acute inflammatory condition -localized pain erythema, swelling, and heat.
Streptococcal infection : Small breaks of skin Staphylococcal cellulitis: larger wounds, ulcers, or abscesses.
diabetics more susceptible
Vascular disease contributes to the development
Venous insufficiency
softer, and there is often erythema, dermatitis, and hyperpigmentation along the distal aspect of the leg, and skin ulceration may occur near the medial and lateral malleoli.
Obesity is commonly associated
Peripheral arterial disease
systemic atherosclerosis in arteries distal to the arch of the aorta.
history of claudication, which manifests as cramp-like muscle pain occurring with exercise and subsiding rapidly with rest. In addition, later in the course of the disease, patients may present with night pain, nonhealing ulcers, and skin color changes.
ankle-brachial index (ABI) of what confirms peripheral artery disease
<0.9
Which of the following diagnostic tests is the best initial test with high predictive value for determining whether your patient has cellulitis or DVT?
venous doppler of lower extremity
what is D-dimer used for mostly?
exclude thromboembolic disease where the probability is low.
what can predict pre-test probability of having DVT?
Well’s criteria
labs to order to decipher between DVT and cellulitis
CBC
HgbA1c
BMP, BUN, Cr
The Wagner Grading System
grade of ulcer
Grade 1: Diabetic ulcer (superficial)
Grade 2: Ulcer extension (involving ligament, tendon, joint capsule or fascia)
Grade 3: Deep ulcer with abscess or osteomyelitis
Grade 4: Gangrene forefoot (partial)
Grade 5: Extensive gangrene of foot
grade 1 and 2 of wagner treatment
outpatient: extensive debridement, local wound care, and relief of pressure.
If significant erythema or purulent exudate, then treatment for infection is warranted.
grade 3 wagner treatment
eval for osteomyelitis and PAD before address ulcer
at least a brief hospitalization is required to address these issues.
grade 5 wagner treatment
emergent hospitalization and surgical consultation, often resulting in amputation.
lethal consequence of DVT
PE (death within 1-2 hrs)
In order to treat DVT on an outpatient basis…the patient must be
Hemodynamically stable
With good kidney function
At low risk for bleeding
The home environment must be Stable and supportive
Capable of providing the patient with daily access to INR monitoring (if using warfarin as the anticoagulant)
outpatient treatments of DVT
rivaroxaban or apixaban alone
or
low molecular weight heparin (LMWH) overlapping with the initiation of warfarin
inpatient treatment of DVT
unfrationated heparin overlapping with the initiation of warfarin
Advantages of Low-Molecular Weight Heparin (LMWH) over Unfractionated Heparin
- -Longer biologic half-life so subQ 1-2x/day
- -Laboratory monitoring is not required
- -Thrombocytopenia less likely although periodic monitoring of platelets may be needed
- -Dosing is fixed
- -Bleeding complications are less common
- -can be used outpatient
advantage to unfractionated heparin over LMWH
immediately shut off and reversed in the case of bleeding due to its very short half-life.
warfarin needs to be titrated how frequently and to what dose of INR
very three to seven days to an INR of 2.0-3.0.
warfarin disadvantages
highly variable dosing range,
frequent laboratory monitoring,
med-med interactions
factor Xa inhibitors advantages
not requiring weekly lab monitoring of INR- adhere
just as effective and safer
factor Xa inh disadvantages (Rivaroxaban and apixaban )
high cost and difficulty in reversing the anticoagulation in the face of a bleed.
Direct thrombin inhibitors example
Dabigatran
dabigatran advantages
oral- no lab monitoring
fewer bleeding consequences
Recommended duration of anticoagulation normally (for reasons besides cancer)
3 months
Criteria for Recommended Screening for Inherited Thrombophilia
Initial thrombosis occurring prior to age 50 without an immediately identified risk factor (e.g., idiopathic or unprovoked venous thrombosis).
A family history of venous thromboembolism.
Recurrent venous thrombosis.
Thrombosis occurring in unusual vascular beds such as portal, hepatic, mesenteric, or cerebral veins.
half-life of warfarin
40 hours, that means it will take five to seven days for the steady state to be stable.
wait this long to check INR before readjusting dose
Recommended Action When Goal INR is Overshot
Discontinue warfarin, give Vitamin K 5 mg orally.
prevent bleeding!
