DEEP VENOUS THROMBOSIS AND PULMONARY THROMBOEMBOLISM

Question 1

TRUE OR FALSE: Venous thromboembolism (VTE) encompasses deep-venous thrombosis (DVT) and pulmonary embolism (PE)

Answer 1

TRUE

Question 2

TRUE OR FALSE: Anti-thrombin, protein C, and protein S are naturally occurring coagulation inhibitors. Deficiencies of these inhibitors are associated with VTE

Answer 2

TRUE

Question 3

Clinical risk factors for VTE

Answer 3

Cancer, obesity, cigarette smoking, systemic arterial hypertension, chronic obstructive pulmonary disease, chronic kidney disease, long-haul air travel, air pollution, estrogen-containing contraceptives, pregnancy, postmenopausal hormone replacement, surgery, and trauma

Question 4

The most common gas exchange abnormalities seen in patients with PE are

Answer 4

1. arterial hypoxemia
2. an increased alveolar-arterial O2 tension gradient

Question 5

The following are seen in patients with PE except
A. Anatomic dead space increases
B. Physiologic dead space increases
C. Increased pulmonary vascular resistance
D. Alveolar hyperventilation
E. None of the above

Answer 5

None of the above. All are seen in PE
* Anatomic dead space increases because breathed gas does not enter gas exchange units
* Physiologic dead space increases because ventilation to gas exchange units exceeds venous blood flow through the pulmonary capillaries
* Increased pulmonary vascular resistance - vascular obstruction or platelet secretion of vasoconstricting neurohumoral agents such as serotonin
* Impaired gas exchange
* Alveolar hyperventilation - reflex stimulation of irritant receptor
* Increased airway resistance - constriction of airways distal to the bronchi
* Decreased pulmonary compliance

Question 6

The most common symptom of PE

Answer 6

unexplained breathlessness

Question 7

With DVT, the most common symptom is

Answer 7

cramp or “charley horse” in the lower calf that persists and intensifies over several days

Question 8

TRUE OR FALSE: A normal d-dimer is a useful “rule out” test for PE

Answer 8

TRUE
* Levels increase in patients with myocardial infarction, pneumonia, sepsis, cancer, the postoperative state, and those in the second or third trimester of pregnancy.

Question 9

The most frequently cited ECG abnormality in pE

Answer 9

in addition to sinus tachycardia, is the S1Q3T3 sign: an S wave in lead I, a Q wave in lead III, and an inverted T wave in lead III

Question 10

Which of the following is incorrectly matched:
A. Westermark’s sign - Focal oligemia
B. Hampton’s hump - a peripheral wedge-shaped density usually located at the pleural base
C. Palla’s sign - an enlarged right descending pulmonary artery
D.None of the above

Answer 10

None of the above. All are correctly matched

Question 11

the principal imaging test for the diagnosis of PE

Answer 11

CT of the chest with intravenous contrast

• RV enlargement on chest CT indicates an increased likelihood of death within the next 30 days

Question 12

Second-line diagnostic test for PE, used mostly for patients who cannot tolerate intravenous contrast

Answer 12

Lung scanning

• A high-probability scan for PE is defined as two or more segmental perfusion defects in the presence of normal ventilation.

Question 13

The best-known indirect sign of PE on transthoracic echocardiography characterized by the hypokinesis of the RV free wall with normal or hyperkinetic motion of the RV apex

Answer 13

McConnell’s sign

Question 14

________ is the foundation for successful treatment of DVT and PE.

Answer 14

Effective anticoagulation

Question 15

ANTIDOTE:

Life threatening or ICH due to heparin or LMWH

Answer 15

PROTAMINE SULFATE

Question 16

Antidote for dabigatran

Answer 16

IDARUCIZUMAB

Question 17

Bleeding complications from anti-Xa anticoagulants

Answer 17

ANDEXANET

Question 18

Major bleeding from warfarin

Answer 18

PROTHROMBIN COMPLEX CONCENTRATE

Question 19

Less serious bleeding from warfarin

Answer 19

FFP or VITAMIN K

Question 20

Two principal indications for insertion of an IVC filter:

Answer 20

1. Active bleeding that precludes anticoagulation
2. Recurrent venous thrombosis despite intensive anticoagulation

Question 21

______ and _______ are first line vasopressor and inotropic agents, respectively, for treatment of PE-related shock.

Answer 21

Norepinephrine and Dobutamine

• Norepinephrine increases RV inotropy and systemic arterial pressure. It also restores the coronary perfusion
• Dobutamine increases RV inotropy and lowers filling pressures. It may worsen systemic arterial hypotension unless used in combination with a vasopressor.