DVT/PE Lecture

Question 1

what are DVT/SVT in the upper extremities most commonly a complication of?

Answer 1

PICC/Port line placement

Question 2

what is the VTE rate among high risk populations not receiving thromboprophylaxis?

Answer 2

80 percent

Question 3

what are some examples of high risk VTE populations?

Answer 3

critical illness, cancer, stroke, pregnancy, heart failure, MI, age over 75, previous VTE, prolonged immobility, renal failure, inherited hypercoagulable state

Question 4

do we PPX non-high risk populations for VTE with drugs during their hospital stay?

Answer 4

nope

encourage early and often ambulation +/- mechanical PPX

Question 5

how do we PPX the high risk groups for VTE during their hospital stay?

Answer 5

LMWH or UFH

no need to continue administration beyond acute care stay

Question 6

what is a warning sign for heparin induced thrombocytopenia? how do we manage?

Answer 6

a 50 percent reduction in platelets = red flag

use 4 T's calculator to assess risk
stop ALL heparin type products
give arixta (fondapurinax)!

Question 7

signs and symptoms of a DVT?

Answer 7

lower extremity swelling, pain, discoloration

palpable cord, + homan’s sign (when dorsiflexing foot, feel posterior leg pain), edema

Question 8

what makes up the well’s criteria for diagnosing probability of DVT? (sadly she asked about it for PE so it may be worth memorizing) – 9 things

Answer 8

1. active cancer (TX ongoing or in past 6 month): 1 pt
2. paralysis, paresis, recent plaster immobilization: 1 pt
3. recently bedridden 3+ days or surgery w/in 4 wks: 1
4. localized tenderness along DV system: 1
5. entire leg swollen: 1
6. calf swelling by 3+cm compared to other: 1
7. pitting edema (greater in affected leg): 1
8. collateral superficial veins (nonvaricose): 1
9. alternative dx less likely than DVT: 2

Question 9

according to the well’s criteria, at what score makes a DVT likely?

Answer 9

DVT likely 2+
DVT unlikely less than 1

high probability 3+, moderate probability 1 or 2

Question 10

once our patient is considered high risk according to the well’s criteria, how do we confirm our DX?

Answer 10

ultrasound

Question 11

how do we manage patients with a DVT? include drugs and how long we treat them for

Answer 11

1) admit
2) start IV heparin or SQ lovenox for 5 days
3) start coumadin right away on day 1
4) observe for complications: PE, phlegmasia cerulea dolens
5) get case management on board ASAP to begin coordinating at home SQ injections

Question 12

what is our INR goal when treating patient with anticoagulants?

Answer 12

2-3

Question 13

what is the benefit to using our direct novel oral anticoagulants?

Answer 13

NO heparin overlap needed

can be used as monotherapy!

Question 14

downside to new direct oral anticoagulants?

Answer 14

short half life (5-9 hours)

avoid if egfr less than 30

Question 15

dyspnea, tachypnea, pleuritic pain, cough, orthopnea, DVT symptoms, wheezing, and hemoptysis are all signs of what/

Answer 15

submassive PE

Question 16

to be considered a massive PE, what 2 things are added to the previously mentioned symptoms?

Answer 16

hypotension SBP less than 90 mmHG

RV dilatation and dysfunction (red flag)

Question 17

how do we confirm DX of PE?

Answer 17

helical CT angiogram
then CT pulmonary angiography

V/Q scan only if CT contraindicated (can’t get this urgently)

Question 18

to what area of the hospital should massive PEs be sent to? what about submassive PE?

Answer 18

massive = CCU

med/surg floor on telemetry = submassive

Question 19

what level of care center should a patient with a massive PE be sent to if their PE is amenable to embolectomy?

Answer 19

tertiary

Question 20

should you get the coagulation studies to assess for conditions like factor 5, protein C and S when patient is inpatient?

Answer 20

NO

obtain AFTER initial TX period is over (3 months) and anticoagulation has been stopped

Question 21

what is the anticoagulation plan for PE?

Answer 21

same as DVT

5 days heparin or LMWH; bridge to coumadin

Question 22

if your patient can’t use pharmacologic anticoagulation due to bleeding risk, what is an option for PE ppx?

Answer 22

IVC filter

Question 23

your high risk patient does not show any signs of lower extremity thrombus, should you proceed with placing a retrievable IVC filter?

Answer 23

YES

thrombus may remain undetected in pelvic or calf veins
clots can also reform quickly post embolization

Question 24

do all PE and DVT patients need to be admitted?

Answer 24

no, but this is tricky and depends on the institution

Question 25

you should always get ______ on board ASAP when treating your patient with DVT or PE to help plan discharge

Answer 25

case management