DVT & pulmonary embolism

Question 1

what is deep vein thrombosis?

Answer 1

= thrombus (clot) formation within the lumen in the deep venous circulation (usually legs) but can be anywhere

Question 2

what is a PE?

Answer 2

= thrombus (clot) that has embolised (travelled) & lodged in the pulmonary circulation

Question 3

what is venous thromboembolic disease (VTE)?

Answer 3

= clot formation within the venous circulation

- covers both DVT and PE

Question 4

what are the 2 types of DVT?

and what location are they referring to?

Answer 4

1) DISAL vein thrombosis
= refers to DVT of the calves

2) PROXIMAL vein thrombosis
= refers to DVT of popliteal vein or femoral vein
- termed proximal as they are closer to the heart.

Question 5

what are the 3 things that make up the Virchow’s triad in DVT’s and PE?

Answer 5

1) endothelial injury
2) hyper-coagulable state
3) circulatory stasis

Question 6

what makes up hyper-coagulable state? (abnormally increased state of blood clotting)

Answer 6

• malignancy
• pregnancy & permpartum period
• oestrogen therapy
• inflammation bowel disease
• sepsis
• thrombophilia

Question 7

what makes up endothelial injury?

Answer 7

• venous disorders
• venous vacilar damage
• trauma or surgery
• indwelling catheters

Question 8

what makes up circulatory stasis?

Answer 8

• left ventricular dysfunction
• immobility or paralysis
• venous insufficiency or varicose veins
• venous obstruction from tumour, obesity or pregnancy

Question 9

what are exposing risk factors for VTE?

Answer 9

• surgery
• trauma
• acute medical illness
• acute heart failure
• acute respiratory failure
• ventral venous catheterisation

Question 10

what are pre-disposing (patient characteristics) risk factors?

Answer 10

• history of VTE
• chronic heart failure
• advanced age
• varicose veins
• obesity
• immobility or paresis
• pregnancy
• renal insufficiency
• hormone therapies

Question 11

what are just normal risk factors?

Answer 11

• smokinng
• travel (long haul)
• oral contraceptive pill
• hormone replacement
• protein C or S deficiency
• pregnancy
• day or major surgery
• active malignancy
• prothrombin gene mutation

Question 12

how does DVT present?

Answer 12

• painful
• swollen limb with redness & heat
• tenderness along vein
• sub-acute development
• no other obvious cause

Question 13

how does PE present?

Answer 13

• sudden shortness of breath
• pleuritic pain
  +/-
• collapse
  +/-
• haemopytsis
• hypoxia
• tachycardia
• BP may be low

Question 14

what score can be used to test the probability of having a DVT/PE?

Answer 14

WELLS score
3 = clinical signs & symptoms compatible with DVT
3 = PE judged to be most likely diagnosis
1.5 = surgery or bedridden for more than 3 days during past 4 weeks
1.5 = previous DVT or PE
1.5 = heart rate > 100 min
1 = haemoptysis
1 = active cancer

< 4 = low
4.5-6 = moderate
> 6 = high

Question 15

what isD-dimer?

Answer 15

a breakdown of product of cross linked fibrin

Question 16

what value show their at risk for VT?

Answer 16

High negative predictive value (<98%) for VTE

Low positive predictive value for VTE

Question 17

what should you do if DVT is likely or low risk of PE?

Answer 17

then check D-dimer

Question 18

if D-dimer is high, what should you do?

Answer 18

a scan

Question 19

if D-dimer is normal what can be excluded?

Answer 19

VTE can be excluded

Question 20

how can you determine how and a PE is?

Answer 20

PE = PESI score + patient characteristics

PESI = PE SEVERITY INDEX

• as PE causes right strain & pressure can be risk of deterioration and death

Question 21

when can post thrombotic syndrome occur?

Answer 21

usually within 5 years after idiopathic DVT

Question 22

what is post- thrombotic syndrome characterised by?

Answer 22

• pain
• oedema
• hyperpigmentation
• eczema
• varicose collaterali veins
• venous ulceration

Question 23

what things are included in the PESI score?

Answer 23

• age
• male sex
• cancer
• chronic heart failure
• chronic pulmonary disease
• pulse rate > 110BPM
• systolic BP < 100mmHg
• respiratory rate > 30BPM
• temperature < 36
• altered mental status
• arterial oxyhemoglobin saturation < 90%

Question 24

how do you manage a DVT?

Answer 24

= oral anti-coagulation

- a small subset of patients where THROMBOLYSIS can be considered

Question 25

how do you manage a PE?

Answer 25

= thrombolysis then oral anti-coagulants

- intermediate or low risk = oral anti-coagulation

Question 26

what is thrombolysis the same as?

Answer 26

= fibrinolysis

Question 27

what does thrombolysis do?

Answer 27

aggressive clot destruction

Question 28

specifically, what type of PE should thrombolysis treat?

Answer 28

= massive PE

Question 29

what are the 3 anti-coagulants that could be used?

Answer 29

1) direct oral anti-coagulants
2) vitamins K antagnoists
3) low molecular weight heparin injections

Question 30

what are 2 examples of direct oral anti-coagulants?

Answer 30

1) apixaban

2) rivaroxaban

Question 31

what is an example of a Vit K antagonists?

Answer 31

= warfarin

Question 32

in what types of patients is low molecular weight heparin injections still used?

Answer 32

= active cancer

= PE

Question 33

in provoked VTE with reversible factors, how long should you be given treatment for?

Answer 33

3-6months

Question 34

in provoked VTE with IRReversible factors, how long should you be given treatment for?

Answer 34

= 3-6months or lifelong depending on patient factors

Question 35

in men with unprovoked events, what would you advise?

Answer 35

= long term anti-coagulation unless bleeding tissue

Question 36

in women with unprovoked events, what would you advise?

Answer 36

= HERDOO-2 score and advise by that