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S2 MAP II > DVT and PE > Flashcards

DVT and PE Flashcards

1
Q

which vessels can have a thrombosis?

A

any vessel

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2
Q

venous thronboembolism

  • includes
  • common complication in…
  • occurs most frequently in…
A

includes deep venous thrombosis and pulmonary embolism
common complication in the ICU
occurs most frequently in the calf

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3
Q

which veins are we worried about finding blood clots (VTE) in

A

pelvic veins
axillary or subclavian vein of the arm
femoral vein of the thigh
peroneal vein in the calf

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4
Q

potential causes of a DCT

A 
long flights
immobility due to anesthesia/post surgical
septicemia
cancer
disorder of clotting
atrial fib or other HF
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5
Q

DVT S/S

A 
pain in the calf
calf swelling
redness
Well's criteria
positive Homan's Sign
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6
Q

Dx of DVT

A

ultrasound of the blood vessels
-doppler ultrasonography
very accurate
usually performed in a physician’s office or hospital outpatient diagnostic center

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7
Q

D-dimer test

  • what is D-dimer
  • only present if
  • negative result means
  • positive result means
A

D-dimer is a fibrin degradation product
only present if coagulation process has been activated
negative result practically rules out thrombosis; positive result can indicate thrombosis but does rule out other potential causes

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8
Q

when is a FDP present

A

present in blood after a blood clot is degraded

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9
Q

D-dimer

  • specificity and sensitivity
  • what happens if patient has a high pre-test probability
  • if low pre-test but high D-dimer, what happens
A

high sensitivity
poor specificity
if patient has high pre-test probability of developing a VTE
-anticoagulant therapy is initiated, regardless of D-dimer results
if low and positive test, further testing (duplex US) is warranted

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10
Q

Homan’s Sign

-describe

A

pain occurs at the back of the knee or calf
ankle is slowly and gently dorsiflexed
sensitivity and specificity not optimal

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11
Q

what are the Well’s Criteria?

A

active cancer: +1
bedrest >3 days or recent major surgery: +1
calf swelling >3cm compared to other leg: +1
entire leg swollen: +1
calf tenderness along deep veins: +1
pitting edema in the symptomatic leg: +1
paralysis, paresis, or immobilization of the LE: +1
previous DVT: +1
alternative diagnosis to DVT likely: -2

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12
Q

Wells DVT criteria

  • what is required to be put into each strata
  • DVT risk for each strata
A 
high
->/= 3 points
-DVT risk: 75%
moderate
-1-2 points
-DVT risk: 17%
low
-0 points
-DVT risk 3%
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13
Q

DVT potential complications

A

pulmonary embolus

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14
Q

pulmonary embolus

  • what is an embolus?
  • what happens with a PE
A

if a blood clot were to “embolize,” this means it has borken loose and traveled through the circulatory system where it blocks another blood vessel
piece of the thrombus breaks off, travels through the R side of the heart and into the pulmonary artery
can lodge in one of the smaller pulmonary capillaries

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15
Q

PEs

  • most develop from…
  • can you see them on X-ray
A

most result from DVT

can’t see a PE on X-ray

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16
Q

PE

-what is it

A

clot that moves into your lungs and blocks the blood supply

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17
Q

PE

  • symptoms
  • signs
A 
symptoms
-SOB
-cough
-harp chest pain - sudden
signs
-hypotension
-fainting
-tachypnea
-desaturation of blood
-rapid pulse
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18
Q

PE

-why is it dangerous

A

blocks an artery

  • prevents the exchange of oxygen into the bloodstream
  • causes a decrease of oxygen delivered to the organs and body systems
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19
Q

death rates of patients with PE who recieved

  • mechanical ventilation
  • cardiopulmonary resuscitation
  • thrombolytic treatment
A 
ventilation
-80%
CPR
-77%
thrombolytic
-30%
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20
Q

patients with PE who are stable enough for diagnostic procedures

  • what tests
  • mortality rates
A

spiral CTs and V/Q-scans

mortality rates of 1-2%

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21
Q

VQ scan

  • what is it
  • used for…
A

nuclear medicine imaging study
VQ scans can be used to help diagnose pulmonary embolism in patients who cannot receive iodinated contrast (X-ray dye), such as that used in computed tomographic angiography (CTA)

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22
Q

VQ scan

-how is ventilation determined

A

radioactive chemical is inhaled to evaluate which parts of the lung receive oxygen

23
Q

VQ scan

-when and how is perfusion determined

A

performed after a radioactive chemical is injected into an IV to map the blood flow to the lungs
then compared to the ventilation part

24
Q

prevention of PE method

A

Greenfield filter

25
Q

Greenfield filter

  • how is it introduced
  • function
A

introduced through the jugular vein and is lodged in the inferior vena cava
catches emboli

26
Q

pharmacological Tx of DVT/PE

A

anticoagulants

  • Enoxaparin aka low molecular weight heparin (LMWH) is Tx of choice since mid-90s
  • standard unfractionated Heparin
  • Coumadin a.k.a. Warfarin
27
Q

what interferes with Coumadin function

A 
garlic
St. John's Wort
cranberry juice
ginsent
aspirin
NSAIDs
28
Q

standard unfractionated Heparin

-function

A

does not break down clots that have already formed

allows the body’s natural clot lysis mechanisms to work normally to break down clots that have formed

29
Q

pharmacological prevention

A

use of LMWH prophylactically reduces incidence to 16%
anticoagulants are the most frequently used form of VTE prophylaxis in the at-risk population
LMWH was the most commonly prescribed anticoagulant
mortality in untreated PE is approximately 30%, but with adequate (anticoagulant) treatment, this can be reduced to 2-8%

30
Q

what is the most common preventable cause of in-hospital death

A

blood clots

31
Q

prophylactic prevention of DVT

A

compression hose
sequential compression device (SCD)
preventative anticoagulation e.g. coumadin
mobilizing
pulmonary embolism accounts for 5-10% of deaths in hospitalized patients, making VTE the most common preventable cause of in-hospital death

32
Q

what is used more for VTE prevention?

-pharmaceutical or mechanical

A

pharmaceutical

33
Q

are mechanical prophylaxis used more in surgical or medical patients

A

surgical

34
Q

rate of DVTs in TKA and hip fracture patients

A

31% of TKAs

27% of hip fracture patients

35
Q

how many people worldwide receive VTE prophylaxis?

A

40% medical

58% surgical

36
Q

how effective is VTE prophylaxis in surgical patients

-Cochrane review (pharma + mechanical vs. just pharma)

A

75% reduction when using pharma and mechanical in conjunction

37
Q

VTE is often preventable with…

A

judicious use of preventative measures in the form of thromboprophylaxis and mechanical antiembolism stockings

38
Q

omission of thromboprophylaxis within the first _____ of ICU admission without obvious reasons is associated with a higher risk of mortality in the ICU

A

24 hours

39
Q

mechanical prevention effectiveness

A

mechanical methods reduced risk of proximal venous thrombosis by 50% and pulmonary embolism by 40%
in absence of clear contraindications, patients undergoing a surgical procedure would be expected to derive net benefit from mechanical compression

40
Q

when anticoag is contra’d, what can be used to do mechanical thromboprophylaxis (as it is indicated)

A

graduated compression stockings (GCS)

intermittent pneumatic compression (IPC)

41
Q

thromboprophylaxis by mechanical means alone is recommended for…

A

critical care patients at high risk of bleeding with contraindications to prophylaxis with anticoagulant agents

42
Q

when is anticoag not an option

-when should pharmacologic Tx be started into this situation

A

for acutely ill hospitalized medical patients at increased risk of thrombosis who are bleeding or at high risk for major bleeding
when bleeding risk decreases, and if VTE risk persists, begin pharmacologic thromboprophylaxis

43
Q

when can mobility be used as prevention?

A

when dose of anticoagulation is “therapeutic;” usually within 6 hours
walk as soon and as much as possible with good compression therapy following anticoagulation therapy

44
Q

outcomes of mobility as prevention

A

leads to better outcomes

  • decreased pain
  • decreased swelling
  • decreased occurrence/severity of post-thrombotic syndrome
45
Q

for long-distance travelers at increased risk of VTE (previous VTE, recent surgery or trauma, active malignancy, etc.), what are the recommendations

A

frequent calf muscle exercise, or sitting in an aisle seat if feasible

46
Q

for general and abdominal-pelvic surgery patients at very low risk for VTE, what does the research recommend

A

not specific pharmacologic or mechanical prophylaxis be used other than early ambulation

47
Q

in patients with acute DVT of the leg, what is suggested

A

early ambulation over initial bed rest

48
Q

in patients with acute DVT of the leg and severe pain and edema, what do you do

  • ambulation
  • other therapy
A

ambulation may need to be deferred

reasearch suggests use of compression therapy in these patients

49
Q

early ambulation of acute DVT patients with anticoagulation compared to bed rest

A

not associated with a higher incidence of new PE, progression of DVT, and DVT related deaths
for patients who sufferend moderate or severe pain initially, a better outcome can be seen in early ambulation group, regarding to the remission of acute pain in the affected limb

50
Q

early ambulation was associated with a trend towards…

A

a lower incidence of new PE and new or progression of DVT than bed rest
-trend towards lower incidence of new PE and overall mortality

51
Q

take-home message

A

know the clinical guidelines

52
Q

take-home message

-what are the general clinical guidelines

A

patients presenting with DVT who are able to ambulate do not need to be kept at bed rest
best rest has no influence on the risk of developing PE among patients with acute DVT of the lower limbs
bed rest has a lack of influence even it patients presenting with acute submassive PE

53
Q

APTA’s 5 recommendations (not necessarily for VTE

A

don’t employ passive physical agnets except when necessary to facilitate participation in an active treatment program
don’t prescribe underdosed strength training programs for older adults
-instead, match the frequency, intensity, and duration of exercise to the individual’s abilities and goals
don’t recommend bed rest following Dx of acute DVT after the initiation of anticoagulation therapy unless significant medical concerns are present
don’t use continuous passive motion machines for the postoperative management of patients following uncomplicated total knee replacement
don’t use whirlpool for wound management

S2 MAP II (17 decks)

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