DVT + PE

Question 1

VTE Ix

Answer 1

• D-Dimers (not specific)
• Compression USS (clot will be incompressible)

• May do thrombophilia screen

Question 2

VTE Mx

Answer 2

• Wells’ Score:

• Low-probability (1) → perform D-dimers
• Positive → Compression US

• Med / High (>1) probability → Compression US

Anticoagulate:

• DOAC - apixaban - 3 months
- if haemodynamically unstable - thrombolysis with alteplase

Question 3

When to do a thrombophilia screen

Answer 3

• No precipitating factors
• Recurrent DVT
• Family Hx

Question 4

Preventing VTE Pre-Op

Answer 4

• VTE risk assessment
• TED stockings
• Aggressive optimisation: esp. hydration
• Stop OCP 4wks pre-op

Question 5

Intra-Op

Answer 5

• Minimise length of surgery
• Use minimal access surgery where possible
• Intermittent pneumatic compression boots

Question 6

Preventing VTE Post-Op

Answer 6

• LMWH
• Early mobilisation
• Good analgesia
• Physio
• Adequate hydration

Question 7

Risk factors VTE

Answer 7

Increasing age

Previous VTE

Smoking
Pregnancy or recently post-partum

Recent surgery

Prolonged immobility (> 3 days)

Hormone replacement therapy or COCP

Current active malignancy

Obesity

Known thrombophilia disorder (e.g. antiphospholipid syndrome or Factor V Leidin)

Question 8

Clinical features of VTE

Answer 8

Unilateral leg pain
Swelling

May have:

• pyrexia
• pitting oedema
• tenderness

Question 9

Dabigatran and edoxaban use

Answer 9

require initial treatment with low molecular weight heparin (LMWH) (>5 days)

Question 10

Clinical features of PE

Answer 10

Sudden onset dyspnoea
pleuritic chest pain,
cough
(rarely) 
haemoptysis. 

May have:

• tachycardia
• tachypnoea
• pyrexia
• pleural rub
• pleural effusion (rare).

Question 11

Ix of PE

Answer 11

Score = 4 – PE clinically unlikely - D-dimer test to exclude

Score > 4 – PE clinically likely - CT Pulmonary Angiography (CTPA) scan (or V/Q scan in those with poor renal function)

ECG

Question 12

If poor renal function but needs CTPA

Answer 12

V/Q scan

Question 13

Thromboprophylaxis

Answer 13

Mechanical:

• Antiembolic stockings (AES)
• Intermittent pneumatic compression

Pharmacological- LMWH
- poor renal function (eGFR<30) - unfractionated heparin (UFH)

Question 14

Contraindication to mechanical thromboprophylaxis

Answer 14

Peripheral arterial disease

Active cellulitis

Diabetic neuropathy

Question 15

ARDS

Answer 15

Acute lung injury
- severe hypoxemia

• Acute onset within 7 days
• PaO2:FiO2 ratio <300 (with PEEP or CPAP >5cmH2O)
• Bilateral infiltrates on CXR
• Alveolar oedema not explained by fluid overload or cardiogenic causes

Question 16

Post op causes of ARDS

Answer 16

Direct

• Pneumonia
• Smoke inhalation
• Aspiration
• Fat embolus

Indirect:

• Sepsis
• Acute pancreatitis
• Polytrauma
• Major burns

Question 17

Phases of ARDS

Answer 17

Exudative phase - alveolar discharge

Proliferative phase - surfactant

Fibrotic phase - fibrin deposition

Question 18

Clinical features of ARDS

Answer 18

Dyspnoea

Hypoxia

Tachypneoa

Inspiratory crackles

Acute onset (<7 days).

Question 19

Ix of ARDS

Answer 19

ABG
Bloods - amylase , CRP

CXR

ECG

Sputum culture

Question 20

Mx of ARDS

Answer 20

(i) ventilation - intubation and ITU admission
(ii) treatment of underlying cause

Positive end-expiratory pressure (PEEP) - splint airways and avoids damage caused by the cyclical opening of alveoli

Extra-Corporeal Membrane Oxygenation (ECMO) can be considered