Sketchy Path: Deep Vein Thrombosis and Pulmonary Embolism

Question 1

Review Virchow’s triad and Sketchy’s symbols for each.

Answer 1

• Stasis (e.g., bedbound, prolonged travel –represented by the wheelchair)
• Hypercoagulability (e.g., clotting disorders –represented by the stack of fibrin sticks)
• Endothelial injury (e.g., smoking, surgery –represented by the broken endothelial cobblestones)

Question 2

Describe the patient presentation of DVT.

Answer 2

• Positive Virchow’s triad in history
• Unilateral leg swelling, warmth, and pain (like the swollen, hot, and tender leg held by the guy above the Virchow chair)

Question 3

For assessing DVT, you need to complete ____________ criteria.

Answer 3

Well’s (like the well by the guy with the swollen leg)

Question 4

To rule out DVT –as you would in the case of a low Well’s score –you need to get ________________.

Answer 4

D-dimer levels (like the D branches on the ground)

Question 5

DVTs should be treated with _______________.

Answer 5

heparin and warfarin (represented by the hunter in the window) or IVC filters for those with contraindications to anticoagulation (like the wire cage over the blue chimney)

Question 6

Chronic DVTs lead to what conditions?

Answer 6

• Venous insufficiency (regurgitant leg veins that dilate and cause varicose veins)
• Stasis dermatitis (peeling leg skin and hyperpigmentation from venous congestion)

(Think of the bursting blue pipes and peeling red walls above the DVT pile.)

Question 7

Venous stasis can cause what complication?

Answer 7

Fibrodermatosclerosis: a condition in which the stasis leads to scarring of the skin (represented by the weeds over the peeling red wall)

Question 8

____________ DVTs are more likely to travel to the lungs.

Answer 8

Proximal (like the Rue Iliofemoral sign)

Question 9

Pulmonary embolus causes a ___________ V/Q ratio.

Answer 9

increased (like the giant V and small Q in the “Vive la republiQue” sign)

Question 10

Pulmonary embolism leads to what blood gas abnormalities?

Answer 10

• Low PaO2 (like the blue-faced effigy)
• Increased A-a gradient (like the giant A-frame that the effigy is hanging from and the small a on the effigy’s shirt)
• Respiratory alkalosis (like the girl blowing OH bubbles out the window above the effigy)

Question 11

Pulmonary emboli that cause wedge-shaped infarctions usually affect which part of the lung?

Answer 11

The periphery

In the central part of the lungs, the bronchial arteries provide a lot of blood and thus can assist tissue in need of blood.

(Think of the skull on the tip of the soldier’s wedge-shaped hat.)

Question 12

What two (rare) chest x-ray findings can be seen in PE?

Answer 12

• Hampton sign: area of opaque wedge-shaped necrosis

* Westermarque sign: area of lucency in a pulmonary vessel

Question 13

Large emboli (including saddle emboli) can cause _______________.

Answer 13

right-heart failure due to the increased resistance of the pulmonary vessels (think of the guy with the blue coat and large belly; also, the cork in the heart bottle represents COR pulmonale)

Question 14

The test of choice for diagnosing PE is _______________.

Answer 14

spiral CT (like the black CaT running down the spiral staircase)