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CSI > thromboembolic disease > Flashcards

thromboembolic disease Flashcards

1
Q

Substances which Embolize

A 
Air
Amniotic Fluid
Foreign Bodies
Parasitic Eggs
Septic Emboli
Tumor Cell
MOST COMMON: Thrombus
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2
Q

purpose and components of hemostatic system

A

Purpose: Prevent blood loss due to vascular Injury

Components:
Formed Elements: Cells-Platelets, Monocytes, RBCs
Plasma Proteins-Clotting Factors, Fibrinolytic Factors, Inhibitors

Vessel Wall:
Epithelium
vonWillibrand Factor (vWF)
Collagen
Tissue Factor
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3
Q

steps in hemostasis

A 
Vascular Injury (vasoconstriction)
Primary Hemostasis-Platelet Plug
Secondary Hemostasis-Clotting Cascade: Activate Fibrin
Fibrinolysis
Regulation
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4
Q

arteries vs veins

A

A:
Higher Pressure
More smooth muscle
Atherosclerosis

V: 
More Distensible
Capacitance Vessels
Valves
Virchow’s Triad
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5
Q

arterial thromboembolism

A 
Arterial Occlusive Disease
MI
Ischemic CVA
Mesenteric Ischemia
Vasculitides
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6
Q

venous thromboembolism (VTE)

A 
PE
DVT
Superior Vena Cava Obstruction
Chronic ThromboEmbolic Pulmonary HTN (CTEPH)
Dural Sinus Thrombosis
Portal Vein Thrombosis
Vasculitis-Bechet’s, 
Granulomatosis with polyangiitis
Mesenteric Vein Occlusion
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7
Q

Pulmonary venous thromboembolism

A

aka Pulmonary Embolism (PE)
3rd leading cause of death among hospital pts
Often not recognized ante mortem (before death)
less than 10% of pts receive specific tx

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8
Q

thrombus

A

Most common etiology of emboli
Most Common Site of Origin
Deep Veins of the Lower Extremities (i.e. popliteal, common iliac)
Found in 50-70% of pts with symptomatic PE
Can Form Anywhere!

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9
Q

VTE dx

A

NOTORIOUSLY DIFICULT DIAGNOSIS
Findings depend of size of embolus and preexisting cardiopulmonary disease
Common signs and symptoms are not specific

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10
Q

VTE s/s

A

Dyspnea
Pain on inspiration
Tachypnea

Others:
Cough
Hemoptysis
Leg Pain
Tachycardia
Palpitations
Crackles
Homan’s Sign (pain with dorsiflexion of foot)
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11
Q

VTE ddx

A 
Pneumonia
Lung Cancer
MI
COPD
Asthma
Traumatic Injury
Muscle Strain
Costochondritis
Inhalation Injury
Aortic Aneurysm
Congestive Heart Failure
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12
Q

virchow’s triad

A

Stasis
Hypercoagulability
Endothelial Injury

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13
Q

virchow’s triad: stasis

A

Prolonged immobility:

post orthopedic surgery,
Low Cardiac Output
Pregnancy
Post CVA
Travel (Air, Car)
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14
Q

virchow’s triad: hypercoagulability

A 
Medications: 
Oral Contraception, Hormone Replacement
Malignancy
Genetic: 
*Factor V Leiden*
Protein C/S/antithrombin III 
deficiency/dysfunction 
prothrombin gene mutation
hyperhomocysteinemia
antiphospolipid antibodies
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15
Q

virchow’s triad: endothelial injury

A

Traumatic Injury
Recent Surgery
Previous Thrombosis

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16
Q

PE clinical findings: EKG

A

Abnormal in about 70% of pts with PE

Most Common Finding: Sinus Tachycardia (most common!!) and Nonspecific SR and T wave changes

Right Heart Strain: RBBB, Right Axis Deviation, S1Q3T3

prominent S wave in 1, Q wave in 3, T wave in 3 ?

17
Q

PE clinical findings: ABG

A

Usually Respiratory Alkalosis
Abnormal pO2 and Alveolar-arterial O2 gradient
NOT DIAGNOSTIC
Profound Hypoxia with Normal Chest X-ray THINK PE

18
Q

PE lab findings: D-dimer

A

Fibrin Degradation product
Sensitivity 95-97%, Specificity 45%
NO diagnostic threshold established for positive result: may be elevated in inflammation/trauma/infection
*BEST INFORMATION WHEN NEGATIVE (SN-OUT: good at ruling out when negative)
Negative : less than 500mcg/L, Likelihood ratio 0.11-0.13

19
Q

PE other lab findings

A

Serum Troponins, BNP typically elevated in PE

Not Useful in diagnosis, correlate with adverse outcomes

20
Q

PE imaging

A

Chest Xray
Useful to rule out other etiologies: pneumonia, CHF, etc

Most Frequent findings:
Atelectasis, Parenchymal Infiltrates, Pleural Effusion

Uncommon Findings
Westermark Sign
Hampton’s Hump

21
Q

Westermark’s Sign

A

prominent central pulmonary artery with local oligemia

Absence of vascular markings distal to engorged central pulmonary Vein

22
Q

Hampton’s Hump

A

pleural based areas of increased opacity representing intraparenchymal hemorrhage

23
Q

PE clin findings: CT angiography

A

Requires IV contrast dye (don’t want to give to renal failure pts)

Primary finding suggestive of PE:

Intravascular filling defect

Very sensitive for central vascular filling defects

~80% sensitive, 96% specific
15-20% false negative rate

24
Q

CT angiography Secondary Findings suggestive of PE

A

Abrupt arterial cutoff, asymmetrical blood flow, prolonged or slowed filling

25
Q

Normal CT chest requires ??

A

initiation of empiric therapy (high pretest probability) or further testing (V/Q scan, etc.)

26
Q

CT pics

A

saddle embolus: very concerning finding

27
Q

PE clin findings: Ventilation Perfusion (V/Q) scan

A

Perfusion assessed by injection of radiolabeled albumin injected into venous circulation

Ventilation assessed by records distribution of inhaled radio labeled gas

The two images are compared, looking for defects

Criteria for assessment are complex, confusing and not standardized

28
Q

Ventilation Perfusion (V/Q) scan reported in terms of ??

A

probability: low, intermediate, and high

PIOPED1;
If low, 14% probability of PE
Combined with low pretest probability, lowers risk to 4%

If indeterminate, low or intermediate probability, further testing required

29
Q

Venous Thrombosis Studies: Venous Ultrasonography

positive test ??

A

Incompressibility of common femoral or popliteal veins

In a patient with appropriate symptoms
Positive predictive value 97%

Negative Test: Full compressiblity at both vessels
Negative Predictive value 98%

Less accurate in distal thrombi, recurrent thrombi, and asymptomatic patients

30
Q

Wells Criteria: scoring systems to assess PE Risk

A

3: Clinical Signs and symptoms of DVT:
Unilateral edema, and pain with palpation
3: Alternative Diagnosis Less likely than PE
1.5: Pulse >100bpm
1: Immobilization >3days in past 4 wks
1: Previous DVT/PE
1: Hemoptysis
1: Cancer (With Tx w/in past 6 mo. or Palliation)

Total >4pts: Imaging warranted
Total

31
Q

PE/DVT preventable?

A

ARE preventable

Risk Assessment for Surgical Patients

32
Q

pts @ High risk for PE/DVT

A 
Major orthopedic procedure/arthroplasty
Abdominal/pelvic cancer undergoing surgery
recent spinal cord injury
major trauma w/in previous 90days
>3 intermediate criteria
33
Q

pts @ Intermediate Risk for PE/DVT

A

Ambulation less than 2x/day
Active Inflammation/infection/malignancy, Major Non orthopedic surgery
h/o VTE, CVA
Central venous access/PICC line
BMI greater than 30
OCP/HRT use
Immobilization more than 72hrs Hypercoagulable state
nephrotic syndrome
burns, cellulites’, varicose veins, paresis
Systolic Heart Failure
COPD exacerbation

34
Q

pts @ low risk for PE/DVT

A

Minor procedures, age younger than 40 without addition risk factors
Ambulatory with expected length of stay less than 24hrs

35
Q

PE/DVT interventions

A

Sequential Compression Devices (SCDs)

Medication:
Heparin
Lovenox

36
Q

pulmonary VTE tx

A

Heparin: binds ATIII, accelerates inact of thrombin factor 10a, 9a

thrombolytic therapy:
Thrombolytic Therapy
Streptokinase, urokinase, alteplase(tPA)
Systemic or catheter directed tPA

IVC filter: short term, Can increase PE risk in the first two years of therapy
Must be Removed

embolectomy: Rare, Reserved for critically ill patients after unsuccessful thrombolytic therapy

CSI (75 decks)

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