Clin Med: Venous Thromboembolic Disease Flashcards
Three key components to thrombus formation (virchow’s triad)
stasis
hypercoagulability
vessel wall injury
Presentation of DVT
may be asymptomatic
Ipsilateral LE edema (usually not pitting)
LE erythema
LE pain
LE warmth to touch
palpable cord
Homans sign
passive dorsiflexion of the ankle with knee at 30 degrees – calf pain
DVT work up
d-dimer
duplex venous ultrasound (dx)
contrast venography (gold standard)
Interpretation of Well’s criteria for DVT:
0 or less
1-2
3 or higher
DVT unlikely
moderate risk
DVT likely
Most likely cause of pulmonary embolism
DVT
Location of PE
saddle
lobar
segmental
sub-segmental (more likely to cause lung infarct or pleuritis)
Saddle Pulmonary embolism is
large PE that straddles the bifurcation of the PA
Occlusion of both the L and R pulm arteries
Presentation of PE
largely based on size and location
dyspnea
pain with inspiration
cough
leg pain
hemoptysis
wheezing
chest pain
Physcial exam: PE
tachycardia
tachypnea
crackles
S4
Pleural friction rub
cyanosis
hypoxia
Work up PE
labs (preg testing)
ECG
Duplex US
POCUS ECHO
CXR
CTPA (requires contrast may be contraindicated in CKD patients) is the preferred dx test!
Fleischner’s sign
enlarged PA
Westermark sign
last of distal pulmonary vasculature
Hampton’s hump
wedge shaped pulmonary infarct
PE ECG findings
may show patterns of R heart strain
tachycardia
POCUS PE showings
assessing for R ventricular dilation
D sign
potential massive PE (saddle most likely)
Well’s criteria treatment:
0 or less
1-2
3 or more
DVT ruled out
D-dimer
Ultrasound
if positive d-dimer and negative US then recheck in a week
PERC score to ______ PE
r/o
PERC is used when well’s score is ______ than ____
greater
2
VTE treatment: PE
mainstay of tx is anticoagulation (heparin/ LWMH)
massive PE (hemodynamic instability) – thrombolytics
embolectomy
IVC filter is to treat
IVC filter treat DVT treatment to
used when there are contraindications to
treat VTE
prevent clot from going into the pulmonary system
contraindication to anticoags
two types of IVC filter
Retrievable or permanent
Duration of treatment for VTE:
Major transient risk factor (provoked) =
Cancer - related =
Unprovoked =
Recurrent unprovoked =
Underlying hypercoagulable state =
3 months + prophylaxis for subsequent exposures
3-6 months or as long as cancer is active
min of 3 months, possible indefinite if no bleeding risk
indefinite
indefinite
Mechanical prophylaxis
compression socks
intermittent pneumatic compression devices
encourage early mobilization
Pharmacologic prophylaxis
LMWH and low dose UFH preferred for medical pts
Therapy for surgical pts as well
Thrombophlebitis is
inflammation of the vein
Thrombophlebitis is most commonly secondary to
PICC lines
IVs
Thrombophlebitis can lead to
thrombosis or infection (septic phlebitis)
______ is the most common cause of infection
Staph aureus
Presentation of superficial thrombophlebitis
pain
induration (hardened skin)
erythema (linear)
tenderness
palpable cord
sx consistent with course of vein
Presentation of septic phlebitis
fever
chills
other sx from superficial thrombophlebitis as well
Treatment of Thrombophlebitis
remove any offending lines
inflammation is usually self-limiting in 1-2 weeks
heat and NSAIDs for sx treatment
anticoag not usually indicated
if extensive – ?surgery
treatment of septic Thrombophlebitis
vancomycin + ceftriaxone 7-10 days +/- surgery
What has to occur to consider it a “massive” PE (not just size)
hemodynamically unstable
Treatment for PE in CKD pts
heparin
NOT LOVENOX
Treatment for massive PE
tPA
