Clincial Presentation Of DVT And PE Flashcards
Virchows triad
Describes the three broad factors that are thought to contribute to the development of a venous thromboembolism
Consists of
- endothelial damage
- venous stats
- Hypercoagulability
Other factors outside of Virchow’s triad that can lead to a VTE (venous thromboembolism)
Smoking
Coagulapthies
Prolonged inactivity/ immobility
Obesity
Oral contraceptives
Pregnancy
Stroke
Cancer
CHF
Recent surgery
Chronic inflammation
Ranking Transient or persistent provoking factors as it pertains to risk of recurrence with thromboembolism
1) Provoked persistent factors: external risk factors that are persistent through life (i.e new medication that needs to be taken daily, chronic inflammation that causes endothelial damage)
- this causes the greatest risk of recurrence
2) provoked transient factors: external risk factors that only occur once/ resolve themselves (i.e a deep cut that eventually heals)
- the least risk of recurrence
3) Unprovoked factors:
Genetic based
- usually requires indefinite treatment if is recurrent
- second most greatest risk of recurrence
Descriptive Groupings of DVTs
Usually two descriptive groupings
1) upper and lower extremity
- lower is more common
2) proximal and distal
- proximal to the landmark is more common (use knee as the marker in lower and elbow in upper extremities) and more deadly
Clinical presentation of DVTs
Low grade fever
Leg pain/edema/redness/heat coming off the leg
Tachycardia
Pitting edema
Asymmetric pain/swelling/calf circumfrance
(+)Horman’s sign = pain during dorsiflexion
How does a DVT become a PE?
DVT (especially in the leg) can dislodge and often go straight to the IVC
Normal pathway
Leg/arm -> IVC -> right atrium/ventricle -> pulmonary vein -> lungs
Catagories of the type of PE’s
Can be made up of any of the following
- Fat
- Air
- Thrombus
- Bacteria
- amniotic fluid
- tumors
Thromboses Are classified in one of 3 categories based on size
- massive (5-10%)
- submissive (20-25%)
- low risk/size (65-70%)
Clinical presentation of a PE
Dyspena
Chest pain when taking deep breaths (pleuritic)
Syncope
Hemoptysis
Seizures
Clinical findings include:
- tachycardia
- tachypnea and dyspnea
- hypoxia (blueness/paleness in extremities and face)
(The above 3 are the hallmarks of PE)
- echo/EKG show sings of PE
- crackles in the lungs when auscultation
Wells criteria for DVT
Help calculate the risk of a DVT
1) 0 = not likely
2) 1-2 = moderately likely
3) 3+ =. Very likely
The following are the measurements:
- active cancer = 1pt
- paralysis or recently put in cast = 1pt
- bedridden for 3 days or just had major surgery in the past 12 weeks = 1pt
- tenderness along deep veins = 1pt
- entire leg swelling/ unilateral calf swelled more then 3cm = 1pt/2pt
- pitting edema = 1pt
- superficial nonvaricose veins = 1pt
Another diagnosis is just as likely as DVT = -2pts
Wells criteria for PE
Determines the risk of a PE being present
1) likely if 4+
The following are the measurements:
- came back w/ 2+ on DVT scale = 3pts
- heart rate >100/min = 1.5pts
- immobilizations for 3 days or major surgery in the past 4 weeks = 1.5pts
- history of prior PE/DVT: 1.5pts
- cancer = 1.0pts
- hemoptysis = 1.0 pts
What is D-dimer test?
A plasmin-dervied soluble degradation product of cross linked fibrin
- marker of activation coagulation and fibrinolytic systems and is a sensitive marker for thrombolytic activity (98%)
- however, it is not specific for VTE/PE (30%) therefore, elevated D-dimer is not good enough by itself to diagnosis VTE/PE. clinical symptoms must still be worked up on
- because of the lower specificity, NEVER DO DIMER FIRST. Always do history and clinical work up first. If you get a high score in the wells criteria, dont both w/ D-dimer test, just get imaging.
- only get a D-dimer if the score is between 0-2*
How do you diagnosis imagining wise for a DVT?
1) Compression ultrasound.
- note the compression of the vein:
if it doesn’t compress =. Potential thrombus
2) Contrast venography
- “gold standard” where you inject contrast into veins and determine if DVT present, however ultrasound is used more often.
3) CT angiogram
- CT used for PE (Most common imaging outside of ultrasound and less risk than 4-5)
4) Conventional pulmonary angiography
- only used if really high suspicion and are going to need a catheter for thrombolysis anyways
5) V/Q scan: used for pregnancy or patients who cant do 3 and 4 options
- albumin radiolabeled gas and is measured by ultrasound.
- compression ultrasound is used more often since it has lower risks associated with it*
Diagnosis of PE through a EKG
May not show all but these 3 are common characteristics of PE:
1) right ventricular strain pattern
2) sinus tachycardia
3) S1Q3T3 = prominent S wave in lead 1; prominent Q wave and inverted T wave and QR wave in lead 3
4) T wave inversion in lead V3
* these are not specific for PE alone*
Blood work for suspected PE
Elevated troponin and BNP
D-dimer
- note these are not specific by itself*
Baseline measurements to do before treating a VTE/DVT/PE
1) monitor vital signs and determine stable or not stable
- if unstable usually just go straight to surgery
2) get a base line coagulation, hematologic and pregnancy tests/lab before starting medication
3) determine liver/kidney function.
4) determine if inherited thrombophillias exist
