Thromboembolic Disease Flashcards
What are the physical signs of DVT? (4 marks)
Local pain and tenderness
Fever
Swelling
Homan’s sign: pain on dorsiflexion of foot
What does Virchow’s triad consist of? And what does it represent a predisposition for?
- Venous stasis
- Injury to vessel wall
- Blood contents (coagulability)
Predisposing factors for thrombosis
What is used more commonly to image DVT? Doppler US or CT scan?
Doppler US
What is the management of DVT?
Enoxaparin (clexane) until diagnosis made
Doppler US the next day
Continue clexane until INR = 2.5 (or another oral anticoagulant)
Warfarin for 3/12 if clear cause, or 6/12 if no clear cause
Define an embolism
Something that has travelled in the bloodstream, lodged in a vessel and clogged it
Where is a large clot likely to cause severe/fatal haemodynamic compromise?
Bifurcation of PAs
How is a small clot likely to manifest?
Small clot → Distal clot → infarction → pleuritic pain
Define paradoxical embolism and where do symptoms manifest?
A clot that has travelled through a septal defect into the Left side of the heart → systemic manifestation
Stroke, kidney infarction, acute limb infarction
What are the differences and common signs in Acute and Subacute Massive PE
Both:
Tachypnoea, Hypoxaemia, Hypotension, Pleuritic Pain
Acute:
Recent surgery/immobility, Catastrophic CO drop, Cyanosis
Subacute:
SOB due to progressive obstruction
What are the signs for acute minor PE?
SOB
Pleuritic pain
Haemoptysis
Fever
What are the signs for Chronic Thromboembolic PE?
Repeated small emboli → occlusion
Progressive SOB
Pulmonary hypertension (instead of hypotension in subacute massive PE)
Right heart failure
Pleuritic Pain
What are the cardinal signs of PE?
Dyspnoea (SOB)
Tachypnoea (rapid breathing)
Pleuritic Pain
Other: tachycardia, cyanosis, pyrexia, AF, loud/widely split second sound (P2), increased JVP, hypotension, pleural rub, signs of DVT
What is the investigation of choice for PE?
And explain the process
CT pulmonary angiogram
Dye injected into arm, the scan is performed as the dye reaches the pulmonary arteries
Can do ventilation and pefusion scan
What would ABGs show for someone with PE?
High pH (respiratory alkalosis)
Low pCO2 (due to hyperventilation)
Low pO2
Hyperventilation with hypoxia
How would PE show on a CXR?
- May be normal
- May show linear shadows
- Small effusion only (do not get large ones)
- Peripheral wedge
- Elevated diaphragm
- Paucity of vessels (small quantity)
- Small cavity - abscess
What are the basic tests and routine further tests done for PE investigation?
Basic tests: ABGs, CXR, D-dimer, ECG (ACDE)
Further tests: CTPA/Q scan +/- ECHO
The echo for cardiac overload signs
What is the Pesi score?
It is a tool used to predict the 30 day outcome of patients with PE
What is the immediate management of PE?
High flow oxygen + IV fluids + Analgesia
Unfractioned heparin for proven PE
Enoxaparin (clexane) given whilst investigations commence
Thrombolysis (tPA) given if severe haemodynamic compromise (within 12-24hr)
What is the long term management of PE?
Warfarin (vitamin K antagonist) once diagnosis confirmed - aim for INR 2-3
IVC filter placement (rare)
Name two new anticoagulants used for PE treatment, and what is their advantage?
Rivaroxaban - Factor 10a inhibitor (anticoags including X, mean they inhibit 10)
Dabigatran - Thrombin inhibitor
No need for INR monitoring
How would you treat septic emboli?
Prolonged antibiotics
What are the clinical manifestations of inherited thrombophilia? (5 marks)
And how does acquired thrombophilia differ?
Young, recurrent VTE, unusual site, VTE despite anticoagulants, complications in late pregnancy
Acquired: progressive VTE despite anticoagulants
arterial as well as venous VTEs
What is HIT? and what does it predispose?
Heparin-induced thrombocytopaenia, causes VTEs
