Thromboembolism Flashcards
What is thromboembolism?
Formation of blood clot (thrombus)
Obstruct blood vessels
Two types of VTE?
Dvt- deep vein thrombosis
PE - pulmonary embolism
What is DVT?
Formation of blood clot in deep veins like limbs, pelvis, legs
What is PE
Blood clot from DVT travels to blood causing obstruction in pulmonary artery
List symptoms of DVT?
Tenderness
Swelling
Localized Pain
Skin changes
Vein distension (neck vein swollen?
List symptoms of PE
SOB
Chest pain
Haemoptysis (coughing)
What are the risk factors of DVT
Cancer
Pregnancy
Postpartum
Trauma
Surgery
Immobility
>65years
Obesity
Smoking
List the two types of DVT and explain them
Provoked - there is known risk factors
Unprovoked - we don’t know the risk factors
What type of treatment does unprovoked DVT requires?
Long term anticoagulant to prevent reoccurrence
What are the two test used to diagnose DVT?
Well score
D-dimer
What is wells score?
Prediction tool used to estimate the probability that a pt might have DVT or PE
(10-DVT, 7-PE)
What is D-dimer test?
Blood test used to detect presence of elevated levels of substances (D-dimer). They are protein fragments made when blood clot is dissolved in your body
Can you do ultrasound to detect DVT and when should you do it?
Yes
Within 4 hours onset ideally
A positive ultrasound confirm DVT. True or false?
True
After DVT, what is the non drug treatment used to manage leg symptoms?
Elastic graduated compression stockings
When can you not use elastic compression stockings?
VTE reoccurrence after DVT
Preventing post thrombotic syndrome
What is the first line treatment after confirmed DVT or PE?
Anticoagulant - Apixaban, Rivaroxaban
If anticoagulants are not suitable or tolerated, what do you give?
Low molecular weight heparin (enoxaparin, dalteparin sodium, tinzaparin) for Atleast 5 days followed by edoxaban or dabigatran
Continuation of LMWH trt
Lmwh with vitamin k antagonist (warfarin) for atleast 5 days or until INR is atleast 2.0 for two consecutive reading then you’ll just take vitamin k antagonist alone
When can you only use unfractionated heparin with warfarin?
Renal impairment
Renal failure
Inc risk of bleeding
What do you give if creatine level is <15ml/min?
LMWH or
Unfractionated heparin
How many days is the peak therapeutic effect of warfarin after initiation?
5 to 7 days
How long is the treatment for provoked DVT or PE?
Atleast 3 months (3-6 months for active cancer)
What is thrombophillia?
Multifactorial condition where the blood has an increase chance to clot
What is Factor V Leiden?
Genetic mutation, makes people more prone to developing abnormal blood clots in veins. Eg Europeans
What is the main complication of DVT?
Leads to PE- which leads to death
What do you give pregnant women with suspected VTE?
LMWH- enoxaparin, etc
If you are at high risk of haemorrphage, what should you give?
Intravenous heparin
What do you give people who are allergic to heparin or develop heparin induce thrombocytopenia?
Give alternative anticoagulants
What else can you use unfractionated heparin for?
Maintenance of extracorporeal circuits in hemodialysis and cardiopulmonary bypass
What do you use for the reversal of heparin effect?
Protamine sulfate
(Only partial reverse the effect)
Anyone admitted to the hospital is at high risk of VTE, true of false? What do you do when they come in?
True
Assess them to see if suitable to start prophylactic anticoagulants
What is the prophylactic anticoagulant treatment giving to those at risk of VTE after being admitted?
Anticoagulant with LMWH heparin like tinzaparin
List two underlying causes of unprovoked PE?
Malignancy
Inherited thrombophillia
What is PESI score used for prognosis?
(Pulmonary embolism severity index)
It helps to predict patients 30 days mortality.
It guides to the appropriate treatment
How many severity classes are they in PESC score and which one is the highest?
IV classes
IV is the highest (>125)
What do you give for haemodynamic instability in PE
Thrombolysis - Alteplase
10mg IV bolus then
90mg IV infusion over 2 hours
What do you give for stable haemodynamic but patient is hypotensive
Noradrenaline or
Dobutamine 2.5-10mcg
What should women who have given birth/miscarriage/termination be given as prophylaxis and for how long?
LMW heparin 4-8 hours after the event and continue for minimum of 7 days
What is the first and second line mechanical prophylaxis for immobilized woman?
Intermittent pneumatic compression
Or anti embolism stockings
What is the first/second option for pharmacological prophylaxis? And for how long?
LMW heparin or
Fondaparinux sodium
Used for minimum of 7 days
What prophylaxis should be given for people with renal impairment?
LMW heparin or unfractionated heparin
What prophylaxis can you give for people undergoing abdominal, thoracic, cardiac surgery or immobilization?
Fondaparinux
How long should prophylaxis be given in major cancer surgery in abdomen?
28 days
How long should prophylaxis be given in spinal surgery?
30 days
What prophylaxis should be given for pt undergoing elective knee replacement?
Low dose aspirin for 14 days
Or LMW heparin with anti embolism stockings for 14days until discharge
Or rivaroxaban
Not not appropriate give apixaban ot dabigatran
