DVTs Flashcards
What is a DVT?
Blood clot in the deep veins
What is the most common area for DVTs to occur?
Legs
10x more common than upper extremity
Usually starts in calf & spreads proximally
Do distal DVTs have more or less risk of clot embolizing to lungs?
Less risk
Do proximal DVTs (popliteal or femoral veins) have high or low incidence of pulmonary embolism?
Higher
Are varicose veins a significant risk for DVT?
No
Does venous stasis promote or decrease thrombus formation?
Promote
What makes up Virchow’s triad?
Venous stasis
Hypercoagulability
Inflammation
Does thrombosis happen before or after an event of Virchow’s triad has occurred?
After
What increases the risk of DVT? (7)
Family history of DVT Immobilization Recent major surgery/trauma Active cancer/ chemotherapy Age over 60 Systemic diseases Pregnancy, estrogen
Are individual DVT risk findings reliable?
No- you will need to use clinical prediction guidelines to predict likelihood of DVT
What are some findings when a patient has a DVT?
asymmetric calf swelling
(also includes Baker’s cyst in or near popliteus)
asymmetric warmth & redness
acute cellulitis which signifies subcutaneous CT infection
exquisitely tender to touch
asymmetric edema (most likely acute onset)
If a patient has chronic edema & skin changes that include thickening and a dusky color, what is a possible diagnosis?
Chronic Venous Insufficiency
What is chronic venous insufficiency caused by?
incompetent valves in the deep veins
can also be a DVT complication
What could be a helpful treatment for chronic venous insufficiency?
venous compresion
Is chronic venous insufficiency unilateral or bilateral usually?
Can be either
What are some typical findings of chronic venous insufficiency?
medial lower leg skin changes above the ankle
there may or may not be an ulcer
calf muscle cords/ tenderness
Homan’s sign (no longer considered reliable)
medial calf size greater than 3cm larger than other leg (could be from swelling for something other than a DVT as well)
What is used to predict DVT probability?
Clinical prediction guide such as Wells DVT Clinical Prediction Rules
If a patient has bilateral lower extremity pitting edema do they get a point on Wells DVT Clinical Rules?
NO- because it should be unilateral, not bilateral
How long would a patient have restricted mobility (such as bedridden for more than 3 days or major surgery) in order to give them a point on Wells DVT Clinical Rules?
4 weeks
How recent would an active malignancy have to be in order to give a patient a point on Wells DVT Clinical Rules?
Within the last 6 months
If the circumference of one calf over the other is 2cm how many points does the patient receive on Wells DVT Clinical Rules?
0 points- because it has to be greater than 3cm difference
- measure this 10cm below tibial tuberosity
How many points does a patient receive on Wells DVT Clinical Rules if they have varicose veins?
0 points
- 1 point is given for NON-varicose collateral superficial veins
On Wells DVT Clinical Rules what do you deduct 2 points for?
strong alternative to DVT, if there is another diagnosis that is at least as likely as DVT
On Wells DVT Clinical Rules, your patient gets 0 points, what this indicate?
Low probability (3% DVT frequency)
On Wells DVT Clinical Rules, your patient gets 1-2 points, what this indicate?
Medium probability (17% DVT frequency)
On Wells DVT Clinical Rules, your patient gets >2 points, what this indicate?
High probability (75% DVT frequency)
What do you do if you suspect a DVT?
Get an urgent ultrasound done
What do you use a D-dimer blood test for? How do you interpret it?
To test for DVT
Negative= NO DVT
Positive does NOT rule IN a DVT (imaging is required for this)
What is a potentially fatal complication of DVT?
Pulmonary Embolus
What is the classic triad of a pulmonary embolus?
Hemoptysis
Dyspnea
Chest pain
(all 3 occur in less than 20% of cases)
What is the treatment for a suspected DVT?
Go to the ER! for anticoagulation medication to prevent further clotting
May require meds to dissolve the clot as well
What are 5 red flags for a cardiac problem?
Chest Pain!! Palpitations Pre-syncope/syncope SOB/DOE LE Swelling (edema)
What are the 2 categories of chest pain?
Visceral (vague)
Pleuritic
Explain how the patient might present if they are having cardiac visceral pain.
Hard for patient to localize/ describe
Not made worse by palpation, changes in body position, or taking deep breaths
What is a typical example of cardiac visceral pain?
Angina (cardiac ischema)
When do you see cardiac pleuritic pain?
When the pericardium is inflamed and irritates the parietal pleura= pericarditis
Why is parietal pleura so pain sensitive?
Because parietal pleura lines the chest wall in close proximity to the intercostal nerves
Explain how a patient might present if they are having cardiac pleuritic pain.
Easier to localize/describe (usually retrosternal or left chest & sharp pain)
Not made worse by palpation but WORSE with breathing and lying supine
What might make pericarditis pain feel better?
Sitting & leaning forward
When is pleuritic chest pain most often seen?
Lung conditions & pericarditis & 14% of MIs
Differential Diagnosis for chest pain can also include what other conditions?
GI problems
Anxiety
Musculoskeletal conditions
Is pre-syncope/syncope specific to heart disease?
No
What leads to pre-syncope/syncope?
Global reduction of cerebral perfusion
What do benign forms of pre-syncope/syncope tend to have?
Prodrome
How long is the prodrome for vasovagal syncope?
about 2.5 minutes
If your patient has short (3-5secs) or no prodrome what can this indicate?
Cardiogenic syncope (usually this is not benign and must be investigated further)
Are palpitations alone specific to heart disease?
No
What does a combo of palpitations and pre-syndope/syncope indicate?
Arrhythmia
must investigate further
What is a potential indicator for cardiovascular disease?
Peripheral arterial disease
What is a modifiable cardiovascular risk factor?
Stacking (finger stacking)
What are the non-modifiable risk factors for CVD?
Patient age
Male = 45, Female = 55 results in CVD risk increase
Family history of premature heart disease in a first degree relative (premature male= 55, female = 65)
What does Nitric Oxide promote?
Vasodilation (and can limit platelet clotting)
What are some pathophysiological factors that can contribute to CVD?
arterial "stiffness" injured endothelium (due to decreased NO) increased risk of vasoconstriction & clotting
CV risk factors can lead to activation of endothelium. What does this refer to and what does it cause the formation of?
Activation of endothelium refers to leukocyte recruitment & this leads to the formation of Foam Cells
In CVD, what happens after foam cells are formed?
An inflammatory cascade is triggered in artery wall which causes plaque formation.
What area of an artery is most prone to atherosclerosis?
Arterial bifurcations
What is the strongest modifiable risk of CVD?
Diabetes mellitus
some risk present even when glucose levels are under control
What is the second strongest modifiable risk of CVD?
Smoking (proportional to number of smoked and depth of inhalation)
Second hand smoke also counts
Outside of diabetes and smoking, what are other modifiable risks of CVD?
Sedentary lifestyle Body weight/ obesity Hypertension High LDL levels Hypertriglyceridemia Low HDL
What causes most heart attacks?
Plaque rupture & subsequent clot formation
Do all heart attacks occur in patients with high LDL levels?
No
Explain how MI often happens due to high LDL.
Oxidation of LDLs causes inflammatory cascade, and this inflammation may lead to plaque rupture= CV event
Explain the cholesterol treatment controversy
- statin meds for those with normal LDL levels to stabilize plaques
EIP suggests this is what leads to decreased CV deaths
What can lead to hypertriglyceridemia?
Obesity
Uncontrolled diabetes
Chronic alcoholism
