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Clinical Medicine I > Exam 4: DVT and PE > Flashcards

Exam 4: DVT and PE Flashcards

1
Q

What are the three components of Virchow’s Triad regarding DVT?

A

Stasis + Hypercoaguability + Vessel wall injury

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2
Q

What is the biggest risk for developing recurrent VTE?

A

previous thrombotic event

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3
Q

The most common chronic conditions that lead to increased risk for VTE are…

A

Malignancy

Antiphospholipid Ab Syndrome

Myeloproliferative disorder

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4
Q

What common causes of transient state are linked to increased VTE risk?

A

surgery, trauma, immobilization or a central venous catheter

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5
Q

What female specific factors commonly increase the risk for developing VTE?

A

pregnancy, hormonal contraceptives

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6
Q

What are the two most common inherited risk factors for VTE development?

A

Factor V Leiden mutation and prothrombin gene mutation

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7
Q

A patient complains of unilateral pain of the right lower extremity. The patient was recently discharged from the hospital after having a bone tumor removed.

What do you expect to find on physical exam?

A

warmth, erythema and swelling > 3 cm of affected lower extremity.

(+) calf pain and homan’s

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8
Q

A wells score of 3 or more indicates what?

A

high probability of DVT

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9
Q

A wells score of 1-2 indicates what?

A

moderate probability of DVT

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10
Q

A patient you suspect of DVT scores a 1 on the Well’s criteria. What test should you order and why?

A

D-Dimer only used to r/o DVT.

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11
Q

A patient with a wells score of 0 is referred to your service. The patient was recently hospitalized, is elderly, has hx of malignancy and renal insufficiency.

D-Dimer is elevated. Is this concerning for DVT?

A

no. d-dimer is commonly elevated in pts with this presentation

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12
Q

The D-Dimer is only used to r/o DVT for what reason?

A

it is not a specific test for DVT. It should not be performed if expected to be positive (wells > 1)

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13
Q

A patient presents with a wells score of 0 and a negative D-dimer. Patient is positive for lower extremity swelling and erythema. Do you still suspect DVT?

A

no.

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14
Q

A patient presents with hx of immobilization, tenderness in lower extremity, calf swelling > 3cm and pitting edema. What is the Well’s score and what test is ordered to confirm suspicion of DVT?

A

Wells 4

order compression ultrasound to show loss of vein compressibility

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15
Q

You have one patient who has a positive ultrasound for popliteal DVT, and one patient positive with a distal DVT.

Do both of these patients receive anticoagulation?

A

Proximal - Absolutely

Distal: if symptomatic

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16
Q

Your patient has a positive DVT in the iliac vein. What is the treatment and for how long should treatment continue?

A

anticoagulation minimum 3 months if provoked, often 6-12 months if unprovoked.

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17
Q

you’ve started a patient with a DVT on coagulation. What should coincide with anticoagulation therapy?

A

early ambulation if sxs are under control

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18
Q

What is the common cause of upper extremity DVT?

A

secondary to catheter placement

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19
Q

a patient presents with dull pain along a vein, induration, redness. Patient is negative for edema. Hx of PICC line, IVDU and hypercoagulability. Do you suspect this to be a DVT? How do you tx this?

A

No. Likely superficial thrombophlebitis.

tx w/ local heat, nsaids.

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20
Q

what is the main goal of therapy when treating a DVT?

A

Preventing development of pulmonary embolism

21
Q

Pulmonary embolism can be classified in one of what 4 ways…

A

Hemodynamic stability: stable or unstable

Temporal pattern: acute, subacute, chronic

Anatomic location: saddle, lobar, segmental, subsegmental

Presence of Sxs

22
Q

a systolic blood pressure of < 90mmHg or drop of 40 from baseline for 15 minutes indicates what type of PE?

A

massive PE, hemodynamically unstable PE

23
Q

A patient presenting with dyspnea, pleuritic pain and hemoptysis should concern you for what?

A

PE…classic presentation of PE

24
Q

A post-operative patient presents c sudden onset of tachypnea, is tachycardic, apprehensive and complains of pleuritic chest pain, expecially while coughing. What should you immediately suspect?

A

PE

25
Q

If a patient you suspect of PE is hemodynamically stable, what does the workup look like?

A

Wells score + D-Dimer and CTPA

26
Q

if a patient you suspect of PE is hemodynamically unstable, what can you use to make a dx?

A

bedside echo to show collapse of right ventricle

27
Q 
Age < 50
HR < 100bpm
Sp02 95 or greater
no hemoptysis
no estrogen use
no hx of DVT/PE
no unilateral leg swelling
no hx of surgery/trauma w/in 4 weeks.

This list is called what?

A

PERC rule

28
Q

If all 8 PERC criteria are fulfilled, should PE still be suspected?

A

no. no further testing needed

29
Q

If a patient has 7 or fewer PERC criteria, what is the next course of action?

A

D-Dimer to r/o PE/DVT.

If positive D-Dimer, CTPA

30
Q

when assessing PE via CTPA, should you use IV contrast?

A

no

31
Q

If CTPA cannot be performed, what is the alternative imaging exam?

A

Ventilation perfusion scan (V/Q Scan)

32
Q

VQ Scan can be interpreted as normal, low probability, intermediate probability or high probability. What is the range of intermediate probability?

A

> 4% but < 96%. represents diagnostic dilemma

33
Q

What can be found on CXR for patients suspected for PE?

A

Hamptons hump and westermark’s sign

34
Q

What supportive therapy may be necessary in tx of PE?

A

O2, intubation, pressers to maintain BP

35
Q

What is the tx of choice for patients with low risk of bleeding, high suspicion of PE?

A

Empiric anticoagulation with SQ LMWH, SQ Fondaparinux, or oral factor Xa inhibitors.

36
Q

when should you consider anticoagulation with IV UFH for PE?

A

severe renal failure, hemodynamic instability, massive illiofemoral DVT, those who are likely to require rapid reversal of anticoagulation.

37
Q

What is now the DOC for long-term anticoagulation therapy and why??

A

oral factor Xa inhibitors

no need for PT/INR testing

38
Q

What reverses UFH?

A

protamine

39
Q

what reverses LMWH?

A

protamine (incompletely)

40
Q

What reverses warfarin?

A

Vitamin K, fresh frozen plasma

41
Q

What inhibits the factor Xa inhibitors?

A

tranexamic acid

42
Q

How long should anticoagulation therapy continue after first episode of PE?

A

3 months

43
Q

if PE was provoked by identafiable risk factors, how long can anticoagulation continue?

A

3 months

44
Q

if a PE was unprovoked, how long should anticoagulation therapy continue?

A

6-12 months

45
Q

When should thrombolytics be considered for PE?

A

unstable patients with massive PE, hypotension and cardiogenic shock

46
Q

What patients should IVC filter be considered?

A

only if anticoagulation is contraindicated.

47
Q

what are the common issues with IVC filter?

A

invasive, high risk of bleeding, risk of recurrent PE

48
Q

who may be considered for thrombectomy?

A

unstable PE for whom thrombolytics are contraindicated

49
Q

When can discharge of a patient with DVT or PE be considered?

A

controlled pain

high probability of compliance

ability to pay for injectable therapies while waiting for oral warfarin

compliance and reliability

Clinical Medicine I (25 decks)

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