Leg Swelling Flashcards
Most significant causes of death
Smoking
Obesity
Diabetes
HTN
What percent of deaths due to PE occur within 1 to 2 hrs?
90%
What is the half-life of warfarin?
40 hrs
- 5 to 7 days to reach steady state
What is an important part of the diabetic foot exam that is often overlooked?
Inspecting the footwear
Diabetic foot ulcers Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
Superficial Ulcer extension (Tendons, ligaments, joint capsule, fascia) Abscess or osteomyelitis Gangrene of forefoot Extensive gangrene
Chronic dull, heavy sensation in leg
Lymphedema
Small breaks in skin (Cellulitis)
Strep infection
Large wounds, ulcers, or abscess (Cellulitis)
Staph
Risk factors for cellulitis
Diabetes
Vascular disease
“Palpable cord”, superficial venous dilation
DVT
Granulocyte infiltration, loss of endothelium, and edema
Inflammatory process associated with DVTs
Most robust risk factors for DVT
Smoking
Obesity
Basics of DVT wells score
- 0 = Low probability
- 1 to 2 = Moderate probability
- 3+ = High probability
Active cancer
Immobilization of legs
Bedridden (3 days) or Major surgery (Last 4 weeks)
Local tenderness along deep venous system
Entire leg is swollen
Calf swollen > 3 cm compared to normal leg
Pitting edema
Collateral superficial veins
Alternative dx more likely (-2)
Test to help determine DVT vs Cellulitis
CBC
Venous doppler (Sensitive & Specific)
D-dimer (Sensitive, but not specific)
Treatment of grade 1 or 2 ulcers
Outpatient
- Debridement
- Wound care
- Decrease pressure
- Treat infection as needed
Treatment of grade 3 ulcer
Rule out osteomyelitis & PAD
- May require inpatient treatment
Treatment of grade 5
Inpatient
- Surgical consult
- Good chance of amputation
Requirements for outpatient treatment of DVT
Stable
Good kidney function
Low risk for bleed
Goals of DVT treatment
Stop growth
Promote resolution
Prevent recurrence
Benefits of LMWH
Longer 1/2 life = Sub Q administration No monitoring Lower risk of thrombocytopenia Fixed dosing Can be used outpatient
Why heparin is an inpatient medication
Requires IV dosing based on body weight
Must be titrated to aPTT
How often should you titrate warfarin
every 3 to 7 days
Which Xa inhibitor can be used instead of heparin
Fondaparinux
Length of anticoagulation
Provoked
Unprovoked
Thrombophilic disorder
Provoked:
- 3 months regardless of cause or bleeding risk
Unprovoked:
- 6 months if low risk for bleed or active cancer
- 3 months if high risk for bleed
Thrombophilic disorder
- Indefinitely
Indications to screen for thrombophilic disorder
Onset before age 50 with out risk factors
Family history
Recurrent thrombosis
Portal, heaptic, mesenteric, or cerebral thrombrosis
How to respond to high INR (> 9)
Hold warfarin
Give oral vitamin K
What if INR was between 5 and 9
Hold warfarin and check INR in 24 hrs
When can you stop the bridge to coumadin
Bridge must last at least 5 days
INR must be >/ 2 for at least 24 hrs
