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2. Supporting Life > Embolism > Flashcards

Embolism Flashcards

1
Q

What is an embolism?

A

An embolism is the lodging of an embolus, a blockage-causing piece of material, inside a blood vessel

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2
Q

What are the different types of emboli?

A
  1. Arterial
  2. Venous
  3. Paradoxical
  4. Direction
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3
Q

What is a paradoxical embolism?

A

An embolus from the veins crosses to the arterial blood system

The most common such abnormality is patent foramen ovale, occurring in about 25% of the adult population

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4
Q

What is an pulmonary embolism?

A

blockage of an artery in the lungs by a substance that has moved from elsewhere in the body through the bloodstream

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5
Q

What are symptoms of a pulmonary embolism?

A 
SoB
Chest pain
Pleuritic pain
DVT
Coughing blood
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6
Q

What are signs of a pulmonary embolism

A 
Hypoxia 
Tachypnoea, tachycardia
Mild fever
Syncope
Hypotension 
Obstructive shock
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7
Q

What are risk factors for developing a pulmonary embolism?

A 
Cancer
Prolonged bed rest
Smoking
Stroke
Genetic conditions
Estrogen-based medication
Pregnancy
Obesity
Post surgery
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8
Q

What causes pulmonary embolisms?

A

About 90% of emboli are from proximal leg deep vein thrombosis (DVTs) or pelvic vein thromboses

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9
Q

What is Virchow’s triad?

A

Virchow’s triad or the triad of Virchow describes the three broad categories of factors that are thought to contribute to thrombosis.

  1. Hypercoagulability
  2. Hemodynamic changes
  3. Endothelial injury/dysfunction
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10
Q

What is the Well’s score?

A

Likelihood of a pulmonary embolism

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11
Q

What factors are part of the Well’s score?

A

Clinically suspected DVT (4 points)
Alternative diagnosis less likely than PE. (3 points)
Tachycardia > 100 (1.5 points)
Immobilisation for more than three days or surgery in the previous four weeks. (1.5 points)
History of DVT or PE. (1.5 points)
Haemoptysis. (1 points)
Malignancy (1 points)

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12
Q

What Well’s score indicates likely PE?

A

4 points or fewer = PE unlikely.

More than 4 points = PE likely.

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13
Q

What investigations would you do for suspected PE?

A 
Saturation, FBC, baseline clotting screen
ECG
CXR
ABG
D-dimer
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14
Q

What are specific test would you use to image the pulmonary vasculature in patients with suspected PE

A

CT pulmonary angiogram (CTPA)

A ventilation/perfusion lung scan

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15
Q

What does D-dimer tell you?

A

fibrin D-dimer is a degradation product of cross-linked fibrin

The concentration increases in patients with acute VTE and provides a very sensitive test to exclude acute DVT or PE

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16
Q

What is the prognosis for pulmonary embolisms?

A

Less than 5 to 10% of symptomatic PEs are fatal within the first hour of symptoms

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17
Q

What is the prognosis for pulmonary embolisms?

A

Less than 5 to 10% of symptomatic PEs are fatal within the first hour of symptoms

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18
Q

What type of embolism causes a petechial rash?

A

Fat embolism

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19
Q

What feature distinguishes a fast embolism from other embolisms?

A

Petechial rash

20
Q

What causes fat embolisms?

A

Bone fractures (especially femur)
Pancreatitis
Bome marrow transplantation
Liposuction

21
Q

How would you manage a pulmonary embolism?

A

Intravenous alteplase or UFH if hypotensive

If patient normotensive, then give LMWH

22
Q

What is the diagnosis algorithm for a suspected PE?

A
  1. Determine 2 level PE Wells score

2A: Wells > 4 –> IMMEDIATE CTPA or anticoagulants
- CTPA positive: diagnose PE and offer treatment
CTPA negative: DVT suspected, vein ultrasound

2B. Wells < 4
- Quantitative D-dimer

23
Q

After a DVT or PE, what medication would you give for secondary prevention?

A

Offer apixaban or rivaroxaban in otherwise healthy patients
- LMWH if they’re not suitable

In active cancer, consider DOAC

24
Q

What is the diagnosis algorithm for a suspected DVT?

A
  1. Determine 2 level PE Wells score

2A. Wells > 4 –> proximal vein ultrasound within 4 hours OR D-dimer
- Scan neg: D-dimer, offer second scan

2B. Wells < 4 –> D-dimer

25
Q

After a DVT or PE, how long would you give medication for secondary prevention

A

At least 3 months

26
Q

What is the advantage of LMWH vs heparin?

A

better bioavailability and longer half-life, simplified dosing, predictable anticoagulant response

27
Q

What is the mechanism of action for heparin?

A

activating antithrombin

28
Q

What do you use LMWH for?

A

Used in the prevention of blood clots and treatment of venous thromboembolism

29
Q

When would you give Antiplase?

A

Used to treat acute ischemic stroke, acute ST-elevation myocardial infarction (a type of heart attack), pulmonary embolism associated with low blood pressure

30
Q

After a DVT or PE, what medication would you give for secondary prevention in people with renal failure?

A

LMWH

UFH

31
Q

In a suspected PE or VTE, what medication would you give while you wait for scans or tests to confirm the diagnosis?

A

Offer apixaban or rivaroxaban

32
Q

What do you need to measure before prescribing apixaban or rivaroxaban?

A

FBC, renal function and hepatic function!

33
Q

What is the mechanism of action of apixaban?

A

Apixaban is a direct inhibitor of activated factor X (factor Xa).

34
Q

What is the mechanism of action of rivaroxaban?

A

Rivaroxaban is a direct inhibitor of activated factor X (factor Xa).

35
Q

What is the correct dose of rivaroxaban for treatment PE or DVT?

A

Initially 15 mg twice daily for 21 days, then maintenance 20 mg once daily

36
Q

What is the correct dose of apixaban for treatment PE or DVT?

A

Initially 10 mg twice daily for 7 days, then maintenance 5 mg twice daily.

37
Q

What is the correct dose of rivaroxaban as prophylaxis for DVT?

A

10 mg once daily for 2 weeks, to be started 6–10 hours after surgery.

38
Q

What is the correct dose of apixaban as prophylaxis for DVT?

A

2.5 mg twice daily for 10–14 days, to be started 12–24 hours after surgery.

39
Q

What are intrinsic risk factors for DVT?

A 
A history of DVT. 
Cancer (known or undiagnosed). 
Age over 60 years. 
Being overweight or obese.
Male sex. 
Heart failure.
Smoking
40
Q

What are temporary risk factors for DVT?

A 
Recent major surgery. 
Recent hospitilisation. 
Recent trauma. 
Chemotherapy.
Significant immobility
41
Q

When would you suspect DVT?

A

Unilateral localised pain
Tenderness
Oedema, redness, warmth

42
Q

What happens when blood is exposed to the subendothelial space after injury to a vessel?

A
  1. Changes in platelets
  2. Exposure of subendothelial tissue factor to plasma factor VII, which ultimately leads to cross-linked fibrin formation
43
Q

What factors does clotting factor VII activate?

A

IX and X

44
Q

What does clotting factor X do?

A

Activates prothrombin to thrombin

Factor X acts with co-factor FVa

45
Q

What does thrombin do?

A

Activates fibrinogen into fibrin, which which strengthens the platelet plug

Also activates factor XIII

46
Q

What enzyme breaks down blood clots?

A

Plasmin

2. Supporting Life (11 decks)

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