DVTs and PEs

Question 1

Most common EKG abnormality for PE (pulmonary emboli)?

Answer 1

Sinus Tachycardia

Question 2

Over 90% of acute PE cases are due to what?

Answer 2

Emboli originating from lower extremity DVTs

Question 3

What is Virchow’s Triad?

Answer 3

• Vessel wall injury
• Hyper-coagulability
• Venous stasis

Question 4

2 most common hypercoagulable states as risk factors for VTE (venous thromboembolism)

Answer 4

• Factor V Leiden mutation
• Prothrombin gene mutation

Question 5

3 things which cause DVT in extremities

Answer 5

• injury
• stasis
• prothrombotic status

Question 6

Common vessel of DVT in leg

Answer 6

Femoral Vein (previously superficial femoral vein)

Question 7

If a DVT and PE occur simultaneously, which one is symptomatic and which is asymptomatic?

Answer 7

Symptomatic DVT

Asymptomatic PE

Question 8

What syndrome occurs if DVT is untreated?

Answer 8

Post-thrombophlebitic syndrome

Question 9

What is a common risk factor that causes UE DVT?

Answer 9

Catheter placement

Question 10

What is a useful scoring system for DVT if there is no quick US available?

Answer 10

Wells Criteria

Question 11

• What lab test is helpful if NEGATIVE for diagnosing DVT?
• Sensitivity of 97%
• Specificity of 45%

Answer 11

D-dimer

(endogenous fibrinolysis almost always causes the release of D-dimers from fibrin clot in presence of DVT/PE)

Question 12

4 causes of elevated D-dimer

Answer 12

• Venous thromboembolic diseaes (DVT / PE)
• Post operative state
• Malignancy
• Normal pregnancy

Question 13

• Test of choice for DVT?
• Test no commonly used?

Answer 13

• Compression US (veins should normally collapse, but will not collapse if DVT is there)
• Contrast venography

Question 14

What is our main reason for treating DVT?

(ON EXAM)

Answer 14

Prevent PE

Question 15

3 timing classifications of PE

Answer 15

• Acute - (24 to 48 hrs)
• Subacute - (days to weeks)
• Chronic (months to years)

Question 16

PE associated w/ SBP <90 or drop in SBP of greater than 40 for over 15 minutes

Answer 16

Massive PE

Question 17

PE associated w/ pt not being hypotensive, but has either RV dysfunction or myocardial necrosis

Answer 17

Submassive PE

Question 18

Small or low risk PE

Answer 18

Non-massive PE

Question 19

• Main symptom of PE
• Main sign of PE

Answer 19

Sxs: SOB or dyspnea

Signs: Tachypnea

Question 20

Troponin is increased in pts w/ DVT or PE?

Answer 20

PE (57% of pts)

Question 21

EKG sign “classic” for PE? BUT, only seen in <10% of pts

Answer 21

S1 Q3 T3

Question 22

What is a pathognomic CXR finding for PE? (but is a very rare finding)

Answer 22

Hampton’s Hump

(pleura based shallow wedge shaped consolidation in lung periphery)

Question 23

What is this?

Usually occurs in pts w/ pre-existing cardiopulmonary disease.

Answer 23

Pulmonary Wedge Sign

Question 24

A V/Q scan to dx PE is positive if there is a 1 or greater “____”

Answer 24

Mismatch (ventilation, but no perfusion)

Question 25

Answer 25

Left pulmonary artery PE on CTA (CT angiogram)

Question 26

What is the gold standard diagnostic test of a PE? (highly specific/sensitive)

Answer 26

Angiogram (but is not used frequently due to new generation CTs)

Question 27

What is not a routine diagnostic test for PE, but is widely used to identify right heart hemodynamic changes that indirectly suggest PE & for prognostication?

Answer 27

Echocardiography | (commonly used to see RV failure)

Question 28

What is the initial tx of VTE? (most commonly used)

Answer 28

IV Unfractionated **Heparin** (inhibits clotting cascade by inactivating thrombin)

Question 29

Antidote for Heparin / Reversal

Answer 29

Protamine

Question 30

What med is given for outpatient tx of DVT / Stable PE?

Answer 30

Low Molecular Weight Heparin

Question 31

What med for long term tx of VTE? Is pregnancy category X

Answer 31

**Warfarin** (acts on liver to block vitamin K dependent synthesis coagulant proteins)

Question 32

During the first few days the patient is on Warfarin pt is \_\_\_\_\_\_, so Heparin is a bridge when starting Warfarin.

Answer 32

Hypercoagulable

Question 33

What med for DVT, PE, and non-valvular A-fib?

Answer 33

NOACs / DOACs (factor Xa or direct thrombin inhibitor) Antidote: PCC

Question 34

**Which drug?** * Activate plasminogen to form plasmin, resulting in the accelerated lysis of thrombi * Used for unstable pts w/ PE

Answer 34

Thrombolytics | (Streptokinase, Urokinase)

Question 35

What tx will prevent DVT from propagating to lungs?

Answer 35

IVC filter (absolute contraindication to anticoagulation)

Question 36

3 Prophylactic Measures

Answer 36

* SCD (Sequential compression devices) * TED hose (thromboembolic deterrent) * Low dose SQ Heparin

Question 37

Can a clinically stable pt w/ DVT or PE be tx outpatient?

Answer 37

Yes, give Lovenox or NOACs

Question 38

Who is responsible for monitoring pts anticoagulation?

Answer 38

* PCP * Cardiologist

Question 39

**Pretest Probability scores for PE based on Wells Criteria** * High * Moderate * Low

Answer 39

* **High:** \>6 * **Moderate:** 2-6 * **Low:** \<2

Question 40

**Pretest Probability scores for PE based on Wells Criteria** * High * Moderate * Low

Answer 40

* **High:** 3 or greater * **Moderate:** 1-2 * **Low:** 0