Exam 4: DVT and PE Flashcards
What are the three components of Virchow’s Triad regarding DVT?
Stasis + Hypercoaguability + Vessel wall injury
What is the biggest risk for developing recurrent VTE?
previous thrombotic event
The most common chronic conditions that lead to increased risk for VTE are…
Malignancy
Antiphospholipid Ab Syndrome
Myeloproliferative disorder
What common causes of transient state are linked to increased VTE risk?
surgery, trauma, immobilization or a central venous catheter
What female specific factors commonly increase the risk for developing VTE?
pregnancy, hormonal contraceptives
What are the two most common inherited risk factors for VTE development?
Factor V Leiden mutation and prothrombin gene mutation
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?
warmth, erythema and swelling > 3 cm of affected lower extremity.
(+) calf pain and homan’s
A wells score of 3 or more indicates what?
high probability of DVT
A wells score of 1-2 indicates what?
moderate probability of DVT
A patient you suspect of DVT scores a 1 on the Well’s criteria. What test should you order and why?
D-Dimer only used to r/o DVT.
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?
no. d-dimer is commonly elevated in pts with this presentation
The D-Dimer is only used to r/o DVT for what reason?
it is not a specific test for DVT. It should not be performed if expected to be positive (wells > 1)
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?
no.
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?
Wells 4
order compression ultrasound to show loss of vein compressibility
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?
Proximal - Absolutely
Distal: if symptomatic
Your patient has a positive DVT in the iliac vein. What is the treatment and for how long should treatment continue?
anticoagulation minimum 3 months if provoked, often 6-12 months if unprovoked.
you’ve started a patient with a DVT on coagulation. What should coincide with anticoagulation therapy?
early ambulation if sxs are under control
What is the common cause of upper extremity DVT?
secondary to catheter placement
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?
No. Likely superficial thrombophlebitis.
tx w/ local heat, nsaids.
what is the main goal of therapy when treating a DVT?
Preventing development of pulmonary embolism
Pulmonary embolism can be classified in one of what 4 ways…
Hemodynamic stability: stable or unstable
Temporal pattern: acute, subacute, chronic
Anatomic location: saddle, lobar, segmental, subsegmental
Presence of Sxs
a systolic blood pressure of < 90mmHg or drop of 40 from baseline for 15 minutes indicates what type of PE?
massive PE, hemodynamically unstable PE
A patient presenting with dyspnea, pleuritic pain and hemoptysis should concern you for what?
PE…classic presentation of PE
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?
PE
If a patient you suspect of PE is hemodynamically stable, what does the workup look like?
Wells score + D-Dimer and CTPA
if a patient you suspect of PE is hemodynamically unstable, what can you use to make a dx?
bedside echo to show collapse of right ventricle
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?
PERC rule
If all 8 PERC criteria are fulfilled, should PE still be suspected?
no. no further testing needed
If a patient has 7 or fewer PERC criteria, what is the next course of action?
D-Dimer to r/o PE/DVT.
If positive D-Dimer, CTPA
when assessing PE via CTPA, should you use IV contrast?
no
If CTPA cannot be performed, what is the alternative imaging exam?
Ventilation perfusion scan (V/Q Scan)
VQ Scan can be interpreted as normal, low probability, intermediate probability or high probability. What is the range of intermediate probability?
> 4% but < 96%. represents diagnostic dilemma
What can be found on CXR for patients suspected for PE?
Hamptons hump and westermark’s sign
What supportive therapy may be necessary in tx of PE?
O2, intubation, pressers to maintain BP
What is the tx of choice for patients with low risk of bleeding, high suspicion of PE?
Empiric anticoagulation with SQ LMWH, SQ Fondaparinux, or oral factor Xa inhibitors.
when should you consider anticoagulation with IV UFH for PE?
severe renal failure, hemodynamic instability, massive illiofemoral DVT, those who are likely to require rapid reversal of anticoagulation.
What is now the DOC for long-term anticoagulation therapy and why??
oral factor Xa inhibitors
no need for PT/INR testing
What reverses UFH?
protamine
what reverses LMWH?
protamine (incompletely)
What reverses warfarin?
Vitamin K, fresh frozen plasma
What inhibits the factor Xa inhibitors?
tranexamic acid
How long should anticoagulation therapy continue after first episode of PE?
3 months
if PE was provoked by identafiable risk factors, how long can anticoagulation continue?
3 months
if a PE was unprovoked, how long should anticoagulation therapy continue?
6-12 months
When should thrombolytics be considered for PE?
unstable patients with massive PE, hypotension and cardiogenic shock
What patients should IVC filter be considered?
only if anticoagulation is contraindicated.
what are the common issues with IVC filter?
invasive, high risk of bleeding, risk of recurrent PE
who may be considered for thrombectomy?
unstable PE for whom thrombolytics are contraindicated
When can discharge of a patient with DVT or PE be considered?
controlled pain
high probability of compliance
ability to pay for injectable therapies while waiting for oral warfarin
compliance and reliability
