L3 Thrombosis-Embolism Flashcards by Jackson Barrett

Solid Mass of blood constituents formed within vascular system responsible for nearly 50% of adult deaths?

Thrombus

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Mass of material in vascular system mobile within vessel cable of blocking the lumen

Examples?

Embolism

Thromboembolism (from damage to blood vessel)

Fat Embolus (Fractured Bone)

Air Embolus

Amniotic Fluid

Tumor Fragment (Metastasis)

Septic Emboli

Foreign Body (Talc in IV drug Users)

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What is Virchow’s Triad?

Changes in any 1/3 can lead to thrombosis:

Endothelial Injury
Abnormal Blood flow
Hypercuogulbility

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Intact versus Injured Epithelium?

Intact Epithelium

Anticoagulant

Fibrinolytic

Injured Epithelium:

Platelets adhere to exposed extracellular matrix

–> Endothelium becomes PRO CUAGULANT

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Normal blood flow is __________ while during Stasis/Turbelence _______________

Normal flow is LAMNINAR:

Blood components flow centrally

Clear zone of plasma separating from endothelium

During Statis/Turbulence:

Platelets contact vessel wall

Inflow of clotting factor inhibitors slows

Promotes endothelial cell activation

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Where do Arterial Thrombi usually occur?

Arterial Thrombi typically occur at:

site of endothelial injury

Bifurcation(turbulence)

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Where do venous Thrombi usually occur?

Venous Thrombi occur at site of stasis

90% in Lower Extremities

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Uncommon alteration of coagulation pathway that predisposes to thrombi with Primary (Genetic) Secondary (Acquired)

Hyper Coagulability

Alteration of coagulation pathway that predisposes to thrombi

Uncommon

Causes:

Primary (Genetic)

Secondary (Acquired)

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_______________ are common in cardiac and aortic thrombosis and are used to determine is clot formed during patient’s life or postmorbid

Lines of Zahn:

Pale layers: Platelets mixed w/ Fibrin

Dark Layers: Red Blood cells

Common in cardiac or aortic thrombosis

Used to determine is clot formed during a patient’s life or post morbid

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In which direction do arterial thrombi extend?

Extend in direction towards blood flow

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In which direction do venous thrombi extend?

Extend in direction of blood flow

Propagating tail not well attached

Prone to fragmentation –> embolus

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In which direction do venous thrombi extend?

Extend in direction of blood flow

Propagating tail not well attached

Prone to fragmentation –> embolus

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Which type of thrombi is ALWAYS Occlusive?

Venous Thrombosis

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Which type of thrombi are superimposed on Atherosclerotic lesion and lead to infarction of distal tissue?

Arterial Thrombosis

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______________: form on wall of underlying structure

Heart chamber –> _____________

Aorta–> ___________________

Mural Thrombosis:

Form on wall of underlying structure

Heart chamber –> MI or Arrythmia

Aorta–> Atherosclerosis or Aneurysmal Dilation

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Proximal vs. Distal DVT?

DISTAL Vein Thrombosis:

Deep Veins of Calf

PROXIMAL Vein Thrombosis:

Popliteal, Femoral, Iliac

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Outcomes of DVT? (3)

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Clinical Features of DVT?

Symptoms:

Pain

Swelling (Edema)

Redness (Erythema)

Signs:

Tenderness

Homan’s Sign (Sharp pain in calf upon dorsiflexion)

Increased calf diameter

30% of patients are Asymptomatic!!

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Homan’s Sign is indicative of what?

Homan’s Sign (Sharp pain in calf upon dorsiflexion) is indicative of DEEP VEIN THROMBOSIS

Not done often due to risk of dislodging thrombosis

Phlegmasia Cerulea Dolens (‘___________’)

Very Rare

_________ Venous Thrombosis

Findings:

Venous _______

________ syndrome

Circulatory _______

Phlegmasia Cerulea Dolens (‘painful blue edema’)

Very Rare

Proximal Venous Thrombosis

Findings:

Venous Gangrene

Compartment syndrome

Circulatory Collapse

What is the investigation for DVT?

D-Dimer Blood Test:

D-Dimer: unique product of plasmin mediated breakdown of crosslinked fibrin

Negative D-Dimer + Low Clinical Probability (Well’s Score): excludes possibility of presence of a DVT

Treatment of Acute, Chronic and Massive DVT?

Acute:

Subcutaneous LMW Heparin
Unfractionated Heparin

Chronic

Oral Anticoagulants:
Warfarin
Rivaroxaban
Dabigatram

Massive

Thrombolysis
Surgical Thrombectomy

Prevention of Primary and Secondary DVT?

Prevention of DVT:

Primary

LMW Heparin

Movement after surgery

Compression Stockings

Secondary

Anticoagulation

Inferior Vena Cava Filter (to catch clot before entering heart)

From where do the majority of Pulmonary Emboli arrise?

DVT

Majority are clinically silent

Consequences of Pulmonary Embolism?

_Respiratory Compromise_ Lung not properly profused --\> Inflammation Surfactant dysfunction Atelectasis (collapse of lung) hypoxemias _Hemodynamic Compromise_ Resistance to flow --\> **rise in pulmonary blood pressure** --\> acute right heart failure (**Acute Cor Pulmonale**) --\> **pulmonary infarction** (lung tissue death)

\_\_\_\_\_\_\_\_\_\_\_\_ straddles the bifurcation of pulmonary arteries and is found in autopsy

**Saddle Embolus** straddles the bifurcation of pulmonary arteries and is found in autopsy

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_: Obstruction \>50% of main or proximal artery --\> decreased cardiac output --\> right ventricular dilation (failure) Example? Clinical Presentation?

**_Acute Massive PE_** Obstruction \>50% of main or proximal artery --\> decreased cardiac output --\> right ventricular dilation (failure) **Saddle Embolus** straddling the bifurcation of pulmonary arteries found in autopsy _Clinical Presentation:_ Collapse Central Chest Pain Sudden Death

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Small thrombi travel distally to occlude segmental pulmonary arteries Clinical Signs?

**_Acute Small/ Medium PE_** Small thrombi travels distally to occlude segmental pulmonary arteries _Clinical Signs:_ **Dyspnea** **3 days later --\> pleuritic (membrane surrounding lungs) chest pain**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Exertional Dyspnea Symptoms of right ventricular failure: Peripheral Edema Increased Juglar Venous Pressure (JVP) Hepatomegaly

**_Chronic PE_** Exertional Dyspnea Symptoms of right ventricular failure: Peripheral Edema Increased Juglar Venous Pressure (JVP) Hepatomegaly

Chronic occlusion of pulmonary microvasculature leads to ________________ and \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Chronic occlusion of pulmonary microvasculature leads to _pulmonary hypertension_ and _right heart failure_

Symptoms of Pulmonary Embolism?

Symptoms: Dyspnea –shortness of breath Pleuritic chest pain –pain on taking a breath in Hemoptysis –coughing up blood Collapse

Signs of Pulmonary Embolism?

Signs: Tachypnoea -fast breathing Tachycardia -fast heart rate Hypotension -low blood pressure Fever - if infarcted Right heart failure

Diagnosis of Pulmonary Embolism?

Diagnosis of PE **_Arterial Blood Gas_** **_D-Dimer Blood Test_** - Fibrin Degradation Product **_BNP**_ and _**Troponin_** Increase w/ Heart failure ECG: Sinus tachycardia Imaging: Ventilation/ Perfusion Scan CT Pulmonary Angiogram

Where do Systemic Emboli Arise?

Arises in: Arteries Left of Heart Aortic Aneurism

Consequences of Systemic Emboli?

Tissue infarct Transient Ischemic Attacks: Cerebrovascular Accident (CVA)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_: Shower of small embolisms to brain Full recovery typical

**_Transient Ischemic Attacks_****_:_** Shower of small embolisms to brain Full recovery typical

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\__:_ Large emboli in brain can cause stroke

_Cerebrovascular Accident (CVA):_ Large emboli in brain can cause stroke

What can cause a systemic embolus to originate from a DVT?

**_Paradoxical Embolism :_** Extremely Rare Systemic embolism in venous part of circulation Caused by abnormal blood transfer between the left and right sides of the heart Patent Foramen Ovale Atrial/Ventricular Septal Defect

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_: inherited or acquired defect of Haemostasias leading to disposition to thrombosis

**_Thrombophilia_**: inherited or acquired defect of Haemostasias leading to disposition to thrombosis Autosomal DOMINANT DVT and PE occur at early age, in unusual places

What is Factor V Leiden Mutation?

**_Factor V Leiden Mutation_** Demographics: Predominantly Caucasian 20-30% of DVT patients present w/ 60% of those w/ recurrent DVT Point mutation in gene encoding Factor V Mutant form of _Factor V cannot be degraded_ by activated **_Protein C_** --\> Anti-thrombotic counter-regulatory pathway lost

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Predominantly Caucasian Chromosome 11 mutation --\> 30% increase in circulating Thrombin

**_Prothrombin Gene Mutation_** Predominantly Caucasian Chromosome 11 mutation --\> 30% increase in circulating Thrombin

\_\_\_\_\_\_\_\_\_\_ is the precursor to thrombin

Prothrombin is the precursor to thrombin

\_\_\_\_\_\_\_\_\_\_\_ converts fibrinogen --\> fibrin

**Thrombin** converts fibrinogen --\> fibrin

Antithrombin III deficiency(AD), Protein C deficiency (AD), Protein S deficiency are examples of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Antithrombin III deficiency(AD), Protein C deficiency (AD), Protein S deficiency are examples of **Thrombophilias**

What is Antiphospholipid Syndrome? Diagnosis? Clinical Presentation?

Antiphospholipid antibodies directed against phospholipids bound to plasma proteins **Pro-coagulant effec**t on Protein C, platelets, and tissue factor _Diagnosis_: Test for presence of _anti-cardiolipin_, _anti-β2 glycoprotein 1_ _Clinical_: Arterial/ Venous Thrombosis **Repeated abortions** due to placental thrombosis Strokes