Deep Vein Thrombosis & Pulmonary Thromboembolism - Presentation, Investigation & Therapy

Question 1

Learning Outcomes

Answer 1

Question 2

What is a thrombus defined as?

Answer 2

Clot arising in the wrong place

Question 3

What is the definition of a thromboembolism?

Answer 3

Movement of a clot along a vessel

Question 4

What is virchow’s triad composed of?

Answer 4

Stasis

Hypercoagubility

Vessel damage

Question 5

What are the causes of stasis?

Answer 5

Bed rest

Travel

Question 6

What are the causes of hypercoagubility?

Answer 6

Pregnancy

Trauma

Question 7

What are the causes of vessel damage?

Answer 7

Atherosclerosis

Question 8

What are the parts of virchow’s triad responsible for causing venous thrombosis?

Answer 8

Stasis and hypercoagubility

Question 9

What is the colour difference between venous thrombus and arterial thrombus?

Answer 9

Venous - red thrombus (fibrin and red cells)

Arterial thrombus - White clot (fibrin and platelets)

Question 10

What is the most likely cause of arterial thrombus?

Answer 10

Of virchow’s triad

Principally secondary to atherosclerosis

Question 11

Give examples of venous thromboembolism

Answer 11

Limb DVT

PE

Visceral venous thrombosis

Intracranial venous thrombosis

Question 12

What are the symptoms and signs of DVT?

Answer 12

• Unilateral limb swelling
• Persisting discomfort
• Calf tenderness
• [Warmth]
• [Redness- erythema]

Erythema - (superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries.)

MAY BE CLINICALLY SILENT

Question 13

What is D-dimer?

Answer 13

A fibrin degradation product, a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis

Question 14

How is diagnosis of DVT achieved?

Answer 14

Well’s score - determines the need for D- Dimer test as well as the sensitivty of the D - dimer score necessary

D- Dimer is usually used in patients with a low well’s score

Compression ultrasound is usually performed in patients with a high well’s score or a positive D-Dimer

Question 15

What things are usually taken into consideration when conducting a wells score?

Answer 15

Question 16

What is the potential long - term consequence of DVT?

Answer 16

•Post Thrombotic Syndrome

–Incidence of 20-60% within 2 years of DVT

–Swelling

–Discomfort

–Pigmentation

–Ulceration in severe form

Question 17

What are the symptoms and signs of pulmonary embolism?

Answer 17

• Pleuritic chest pain
• Breathlessness- dyspnoea
• [Blood in sputum- haemoptysis]
• Rapid heart rate- tachycardia
• Pleural rub on auscultation

Question 18

What are symptoms and signs of a massive pulmonary embolsim?

Answer 18

• Severe dyspnoea of sudden onset
• collapse
• Blue lips and tongue- cyanosis
• Tachycardia
• Low blood pressure
• Raised jugular venous

pressure

•May cause sudden death

Question 19

How is pre-test probability of PE determined?

Answer 19

Wells score or Geneva score

Question 20

How is diagnosis of PE achieved?

Answer 20

Pretest probability (geneva or Well’s score)

Blood test: D - Dimer (if low pre - test probability score)

Imaging: If D-Dimer positive or high pre - test probability score

Isotop ventilation / perfusion scan

CT pulmonary angiogram

Question 21

What are the potential long-term consequences of pulmonary embolism?

Answer 21

Most recover fully

Pulmonary hypertension

Question 22

What are the aims of treatment of venous thromboembolism?

Answer 22

Prevent clot extension, embolisation and to prevent recurrent clot

Question 23

What are the treatment options for VTE?

Answer 23

•Anticoagulation is main treatment

–Parenteral (injection) options:

• unfractionated heparin
• low molecular weight heparin

–Enteral options:

• Warfarin
• Direct Oral Anticoagulants (DOACs)

•Thrombolysis reserved for massive PE

Question 24

How do you prevent VTE in the hospital?

Answer 24