CHAPETER 56 VTE/PE Flashcards
Umbrella term for PE and DVT
Venous thromboembolism (VTE)
A consequence of a triggering risk factor for clots, such as recent surgery, trauma, or any condition associated with limb or body immobility
Provoked VTEs
postthrombotic syndrome
Blood clots in the femoral and iliofemoral veins usually form on the valves, leading to scarring and poor function of the venous valves. This causes venous reflux and pooling of venous blood in the legs, leading to varicose veins, pain, swelling, skin hyperpigmentation, and ulcers,
Increase risk of first-time VTE
Inherited thrombophilias
Joint immobility involvement (least to most)
Elbow
Shoulder
Ankle
Knee
Hip
Risk of VTE increases with whole-body immobility or neurologic immobility and with travel _____________
> 8 hours
In general, risk becomes significant after 6 h of continuous travel.
Average time of post-operative PE
> 10 days
The highest-risk surgical p cedures
abdominal surgery to remove cancer
joint replacement surgery
surgery on the brain or spinal cord in the setting of neurologic deficits
Malignancies with high-risk VTE
Adenocarcinoma (pancreatic, ovarian, and colon)
glioblastoma
metastatic melanoma
lymphoma,
multiple myeloma
Malignancies with low-risk VTE
localized breast, cervical, prostate, and non-melanomatous localized skin cancers such as squamous cell carcinoma and basal cell carcinoma not treated with chemotherapy
T/F: Risk becomes significant at 50 y and increases with each year of life until age 80 y
T
VTE risk starts at BMI ___________ and increases with increasing BMI
> 35 kg/m
T/F: PEs can occur in any trimester and postpartum
T
T/F: Highest risk of recurrence is for unprovoked VTE in men, particularly if d-dimer remains elevated
T
T/F: Risk greatest with adenocarcinomas and metastatic disease.
T
Acute leukemias and myeloma confer the greatest risk, particularly when treated with ____________ and _____________ derivatives
L-asparaginase and the thalidomide
T/F: In thrombophilias, Non-O blood type, lupus anticoagulant, shortened aPTT, factor V Leiden, and familial protein C and S and antithrombin deficiency have the strongest risk
T
T/F: Acute limb immobility of two contiguous joints confers the highest risk
T
Bed rest becomes a risk factor at approximately ________
72 h
T/F: In stroke, risk greatest in first month after deficit.
T
T/F: All contraceptives containing estrogen increase risk of VTE including transdermal and transvaginal preparations
T
Hallmark of PE
DYSPNEA unexplained by auscultatory findings, ECG changes, and without a clear alternative diagnosis on chest radiograph
Second most common symptom of PE
Chest pain with pleuritic features
-The classic PE pain is in the thorax between the clavicles and the costal margin that increases with cough or breathing; it is not substernal and emanating from the skin or muscle.
T/F: PE does not predictably alter any vital sign
T
PE findings:
- Unilateral limb swelling (with or without an indwelling catheter), which increases probability of PE diagnosis by three-fold
- Wheezing, which reduces probability of PE by one half
wedge-shaped area of lung oligemia usually from complete lobar artery obstruction
Westermark’s sign
peripheral dome-shaped dense opacification —indicative of pulmonary infarction
Hampton’s hump
T/F: The presence of hypoxemia or dyspnea with clear lungs on physical exam and chest radiography suggests the need to test for PE.
T
ECG patterns of PE
heart rate >100 beats/min
T-wave inversion in leads V 1 to V4
incomplete or complete right bundle branch block
S1-Q3-T3 pattern
Doubles the likelihood of DVT
A difference of ≥2 cm between right and left leg diameter at 10 cm below the tibial tubercle doubles the likelihood of DVT.
calf pain that occurs with passive foot dorsiflexion; low sensitivity and specificity that it has no predictive value
Homan’s sign
Swollen, painful, and pale or white limb with a proximal venous thrombosis
Phlegmasia alba dolens
*poses the threat of limb loss, demanding aggressive treatment that can include clot disruption
A limb with a dusky or blue color
Phlegmasia cerulea dolens
*poses the threat of limb loss, demanding aggressive treatment that can include clot disruption
The d-dimer has a half-life of approximately _____________ and can be elevated for at least after symptomatic VTE
8 hours; 3 days
Formula for D-Dimer
age×10 nanograms/mL
Most common imaging modality for PE
Chest CT angiography
Pulmonary Embolism Rule-Out Criteria Rule
CAPS in ViolET HUES
Clinical Low Probability
Age <50
Pulse <100
SpO2 >94%
Hemoptysis
VTE prior
Surgery
Estrogen Use
Unilateral swelling
***ALL nine factors must be present to exclude pulmonary embolism
WELL’S score for PE
> 6 points = high risk
2–6 points = moderate risk
<2 points = low risk
WELL’S score for DVT
≥3 points = high risk
1 or 2 points = moderate risk
<1 point = low risk
Potential False-Negative Levels of D-dimer
Symptoms >5 days
Pulmonary infarction small isolated
Clots small
Calf vein thrombosis
Lipemia
Potential False-Positive Levels of D-dimer
PASIT MRL
Age >70
Pregnancy
Malignancy/Mets active
Surgery in previous week
Liver dse
RA
Infections
Trauma
Can identify a perfusionndefect when ventilation is normal
Ventilation–perfusion (V/Q) lung scanning
T/F: An age-adjusted quantitative d-dimer assay is the best diagnostic test in patients for whom clinical suspicion is low or moderate based on either gestalt estimation, a Wells’ or simplified revised Geneva score of ≤4, or a “safe” designation according to the PE rule-out criteria rule.
T
T/F: Favor the use of low-molecular-weight heparins over unfractionated heparin for treatment of both PE and DVT in terms of composite outcomes (bleeding and death) and cost
T
T/F: (+) severe renal insufficiency and acute DVT or PE, most experts recommend unfractionated heparin over low-molecular-weight heparin.
T
T/F: Treat upper extremity DVT the same as lower extremity DVT, and consider removing any indwelling catheters associated with clot.
T
-Do not delay unfractionated heparin for thrombophilia testing
T/F: Most DVT can be treated with anticoagulation, but iliofemoral DVT that causes phlegmasia cerulea dolens requires rapid action to reduce the venous pressure
T
Treatment for localized superficial thrombophlebitis
Oral NSAID or topical diclofenac gel until symptoms resolve
-no need for systemic anticoagulation
T/F: There are no universally accepted treatment guidelines for thromboses isolated to the calf veins (soleal or gastrocnemius) or the saphenous vein, although many use 3 months of oral anticoagulation.
T
-Alternatives include no acute treatment, with repeat US in 1 week to identify progression of clot, or outpatient treatment with low-molecularweight heparin
Patients have a systolic blood pressure of <90 mm Hg for >15 minutes;
a systolic blood pressure of <100 mm Hg with a history of hypertension;
>40% reduction in baseline systolic blood pressure
Massive PE
Patients have normal or near normal blood pressure, but with other evidence of cardiopulmonary stress
Submassive PE
Systemic fibrinolysis
in patients with no contraindications to fibrinolysis and any of the following: cardiac arrest; hypotension (any systolic blood pressure >90 mm Hg); respiratory failure, evidenced by severe hypoxemia (pulse oximetry reading <90%) despite oxygen administration, together with evidence of increased work of breathing; or evidence of right-sided heart strain on echocardiography or elevated levels of troponin T or I, or both
Major contraindications to thrombolytic therapy
intracranial disease, uncontrolled hypertension at presentation,
recent major surgery or trauma (past 3 weeks),
metastatic cancer
Only currently approved agent for PE
Alteplase (tissue plasminogen activator) 100 milligrams IV over 2 hours
Treatment of patients with active cancer with low-molecular-weight heparin for at least
6 months
