Thromboembolitic Dx Flashcards
What is Venous thromboembolism
Blood clots forms in the vein which can break free and enter circulation as an embolus and lodge and obstruct a blood vessel
Most common type of Venous thromboembolism
Deep vein thrombosis
What is the name of a superficial venous thrombosis
Phlebitis or superficial thrombophlebitis
Main Origin of DVT
Leg starting at the calf
Virchow triad
Venous stasis
Endothelial damage
hypercoagulable state
Factors contributing to venous stasis
Prolonged bedrest
cast on the leg
Limb paralysis from stroke or spinal cord injury
extended travel in vehicle
Factors contributing to hypercoagulable state
Surgery and trauma which decrease flow of blood increasing chances of blood clots, and general anesthetic used lead to venous vasodilation which increases chances of clots
Malignancy
increased estrogen
all stages of pregnancy
first three months postpartum
elective abortion
oral contraceptive pills
Inherited disorders of coagulation
Protein s, c or antithrombin III deficiencies
Acquired Disorders of coagulation
Nephrotic syndrome with urinary loss of antithrombin III
antiphospholipid antibodies accelerating coagulation
Inflammatory disease leading to to hypercoagulability State
SLE
sickle cell disease
IBD
Factors causing endothelial injury
Trauma
surgery
invasive procedures
Iatrogenic - cv catheters
PathoPhysiology of DVT
Conversion of prothrombin to Thrombin
Fibrin deposition
Coagulation cascade
Propagation of clot due to risk factors
Embolism
Majority of cases how many legs are affected individuals
1
Clinical presentation of DVT
Calf pain or tenderness
Warm local skin
Swelling below the knee indistal DVT
Swelling up to groin in proximal DVT
Superficial venous dilatation
Redskin
cyanosis
leg fatigue
Examination hallmarks in DVT
Palpate distal pulses
capillary refill
palpation and movement of all joints for acute arthritis
Homans sign - Pain in posterior calf or knee with forced Dorsiflexion of the foot
while knee is fully extended
Exam of possible underlying factors
Signs of pulmonary embolism
Breathlessness
chest pain
coughing with blood stains sputum
hemoptysis
Wheezing
lightheadedness
fainting
Unexplain anxiety
accelerated heartbeat
Wells clinical prediction guide for DVT parameters
Active cancer
paralysis or Recents immobilization
Recent bedridden for more than three days or major surgery
localized tenderness
entire leg swelling
calf swelling more than 3 cm
Pitting edema
collateral superficial veins
alternative diagnosis
Investigation of DVT
Blood test- d dimers and INR
imaging studies
Techniques to measure d dimer
Elisa
Latex agglutination
blood agglutination test
Imaging in DVT
Venography
Radiolabeled fibrinogen
Ultrasound
Plethysmography
Mri
Differentials of DVT
Cellulitis
thrombophlebitis
arthritis
Asymmetric peripheral edema due to congestive heart failure,liver disease ,renal failure or nephritic syndrome
lymphangitis
hematoma
lymphedema
ruptured baker cyst
superficial thrombophlebitis
varicose veins
Treatment options of DVT
Anticoagulation
thrombolytic therapy
surgery
filters
compression stockings
Types of anticoagulation
Heparin
warfarin
Percentage of DVT occuring in deep veins of upper extremities
4-13%
Most commonly affected veins of leg
Superficial femoral vein
Popliteal vein
Posterior tibial vein
Peroneal vein
Main cause of upper extremities DVT
Endothelial injury caused by central venous catheter , pacemakers , injection drug use
Superior vena cava syndrome
Subclavian vein compression at thoracic outlet from normal or accessory 1st rib or fibrous band
Common complications of DVT
Pulmonary embolism
Postphlebitic syndrome
Chronic venous insufficiency
Less common complications of DVT
Phlegmasia alba dolens
Phlegmasia cerulean dolens
Venous gangrene
Thrombophlebitis
Symptoms and signs of superficial thrombophlebitis
Palpable, indurated, cordlike, tender, subcutaneous venous segment
Unilateral leg swelling differential
DVT
Cellulitis
Ruptured Baker cyst
Harmatoma
Trauma
Lymphoedema
Tendonitis
Differential of bilateral leg swelling
DVT
Drugs - CCB
Right heart failure
Hypoalbunemia
Liver failure
Chronic kidney disease
Wells criteria for assessment
Active cancer
Paralysis, paresis, or recent cast immobilization of the lower
extremities
Recently bedridden >3 days or major surgery within 4 weeks
Localized tenderness along the distribution of the deep venous system
Swelling of entire leg
Calf swelling by >3 cm compared to the asymptomatic leg
(measured 10 cm below tibial tuberosity)
Pitting edema (greater in the symptomatic leg)
Swollen unilateral superficial veins (nonvaricose)
Alternative diagnosis as likely as or more likely than deep vein thrombosis
If wells criteria is low what are your next steps in investigations
Check D dimer ,
If positive then do emergency Doppler US
If negative then exclude DVT
If wells criteria is moderate or high what are your next steps in investigations
Emergency Doppler US
If negative do D dimer
If positive do anticoagulation therapy
What is d dimer
Product of fibrinolysis , indicates presence and lysis of thrombi
Medical conditions SSOCIATED WITH ELEVATED D DIMER
Liver disease
Trauma
Pregnancy
Infection
Rheumatoid factor positive
Inflammation
Cancer
Recent surgery
Intracardiaque thrombi
SSdx
Nephrotic syndrome
Acute renal failure
Goal of treatment of DVT
PE prevention
Symptom relief
Prevention of DVT recurrence, and complications
DVT treatment
Initial - injectable heparin unfractioned or LMWH
Longer treatment within 24-48h - vitamin K antagonist like warfarin , factor Xa inhibitors like Rivaroxaban or apixaban , direct thrombin inhibitors like dabigatran
Systemic thormbolytic therapy (tPA, streptokinase, urokinase )
Supportive measures in DVT
Analgesics 3-5 NSAIDS
Elevation of legs by pillow
Duration of DVT treatment t
With transient risk factors 3-6 months
Non modifiable risk factors , idiopathic DVT or recurrent DVT at least 6 months
Most common complication of DVT treatment
Bleeding
Where do you place inferior vena cava filter
IVC below renal veins via catheterization of internal jugular vein or femoral vein
Examination of DVT
Heparin monitoring in DVT
