B4-030 CBCL: Venous Thromboembolism Flashcards
treatment for superficial vein thrombosis
- warm compress
- anti-inflammatory
- follow up visit
homozygosity for Factor V Leiden or APLS require
long term anticoagulation
in a young patient with DVT and no known predisposition, what further testing should be done?
hypercoagulable work up for both inherited and non inherited disorders
unusual sites of thrombosis require
more extensive testing
malignancies and other underlying states
APLS should be managed with long term anticoagulation with
vitamin K antagonists
for patients over 50, the d dimer cutoff should be
10x their age
- arterial blood flow to the limb is acutely compromised from severe arterial occlusion
- painful, pale leg
phlegmasia alba dolens
- severe and extensive acute DVT resulting in limb threatening emergency
- venous blood unable to return to heart causing severe edema
phlegmasia cerulea dolens
occurs months/years after acute DVT has resolved
post thrombotic syndrome
catheter directed thrombolytic therapy reduces
the incidence of post thrombotic syndrome in some patients
results most often from compression of left iliac vein from right iliac artery
may thurner syndrome
associated with pelvic inflammatory disease, pregancy, or pelvic fx/surgery
pelvic vein thrombosis
occurs following long bone fx requiring surgery
fat embolization
acute PE with severe tachycardia and hypotension, non pleuritic chest pain
think…
RV strain/RV infarction
PE with pleuritic pain, hemoptysis
think..
pulmonary infarction
if clinical probability of PE is very high, first step is
start heparin therapy, then testing
in a patient with renal failure, what test can be done to dx PE?
VQ scan
in a pregnant patient with suspected PE, what test should be done to diagnose PE?
duplex of lower extremity
a large, acute PE can result in
RV dilation and flattened interventricular septum
classify risk of PE
hemodynamically unstable
PESI >1
RV dysfunction
Elevated troponin
high
classify risk for PE
stable
PESI >1
RV dysfunction
elevated troponin
intermediate high
classify risk of PE
stable
PESI >1
RV dysfunction OR elevated troponin
intermediate low
classify risk of PE
stable
negative on all assessments
low
needed to decide if patient is at high risk of acute mortality
RV/LV ratio
if you do not have echocardiogram, you can get RV/LV ratio from
CT scan
intervention that does not require thrombolytics and can remove large amounts of thrombus quickly
catheter directed mechanical pulmonary thrombectomy
recent bleeds and active malignancy are contraindications for
thrombolytic therapy
pose the highest risk of DVT
orthopedic surgery
a palpable cord is likely to be from
thrombosis of superficial vein
symptoms of DVT
painful, swollen leg
eythema, warmth
patient complains of pain when dorsiflexing foot
homan’s sign
non specific for DVT
indwelling central line is a risk factor for
DVT
considerations for outpatient DVT treatment
- compliance to anticoagulants
- do not have the potential to worsen
pleuritic pain is concerning for
pulmonary infarct
significant leg swelling is concerning for
large thrombus with potential to embolize
patients with malignancy are high risk for VTE and require
long term anticoagulation
best efficacy for long term anticoagulation is seen with
enoxaparin injections
unexplained weight loss is concerning for
malignancy
if you cannot find obvious cause of DVT follow up with
scans to rule out cancer
does heterozygosity for factor V leiden increase the risk of recurrent embolism?
no
increasing incidence and decreasing mortality of PE is due to
increase in use of CTA chest for mild suspicion of PE
when should IVC filters be removed
as soon as no longer necessary
risks of IVC filters
- migration
- fragmentation
- infection
when should an IVC filter be left in place long term?
patients who have ongoing high risk for VTE and contraindication for anticoagulation
if risk of recurrence is low and factors are reversible, how long should the patient take anticoagulants?
3 months
risk of VTE increases significantly at what age
55
are men or women more affected by VTE?
men
key driver in OCCs for increased VTE risk
estrogen
virchow’s triad
- hypercoagulability
- stasis
- vessel wall damage
how does a DVT cause stroke?
embolized DVT can enter arterial circulation via patent foramen ovale
direct thrombin inhibitor
dabigatran
do IVC filters reduce mortality?
no
do IVC reduce recurrence rate of PE?
yes
not DVT
antiphospholipid syndrome requires
lifelong anticoagulation
thromboxane and serotonins cause
pulmonary vasocontriction
leads to RV strain
in patients with a low pretest probability of DVT or PE, what test should be done first?
d dimer
right ventricular stain causes decreased
cardiac output
right ventricular strain is caused by
increased PA pressure and RV wall ischemia from hypoxia
used to indentify severity of PE by showing RV strain
echocardiogram
in critically ill patients with massive PE, what two therapies are life saving?
surgical embolectomy
ECMO
severe and life threatening condition that can be seen years after PE
chronic thromboembolic pulmonary hypertension
CTEPH results in
pulmonary hypertension
CTEPH is more likely following
incomplete resolution of thrombus due to:
-high thrombus burden
-repeated PE episodes
