Thrombosis, Embolism and Pulmonary Hypertension

Question 1

What is the difference between a thrombus and a clot?

Answer 1

Thrombus- inside vessel

Clot- outside vessel

Question 2

Where is thrombosis favoured according to Virchow’s triad?

Answer 2

Stasis (turbulent blood flow), endothelial injury and hypercoagulability

Question 3

What can cause a hypercoagulable state?

Answer 3

Malignancy, pregnancy, hormone replacement, bowel disease, sepsis

Question 4

What can cause endothelial injury?

Answer 4

Venous disorders, valve damage, trauma, surgery, catheters

Question 5

What can cause stasis?

Answer 5

LV dysfunction, immobility, venous insufficiency/obstruction, pregnancy, obesity

Question 6

What two things must happen for a thrombus to form?

Answer 6

Platelet activation and fibrin production

Question 7

What does activating platelets do?

Answer 7

Makes them stickier so they aggregate more platelets and fibrin

Question 8

What is the end point of the coagulation cascade?

Answer 8

Aggregation of fibrin

Question 9

What is the first stage of thrombus formation?

Answer 9

Endothelial injury which exposes collagen

Question 10

What happens in the formation of a thrombus after collagen has been exposed?

Answer 10

Collagen and Von Willebrand factor bind to glycoproteins on platelets which increases platelet integrins

Question 11

What do glycoproteins on platelets bind with?

Answer 11

Fibrinogen

Question 12

Describe the intrinsic coagulation pathway?

Answer 12

Hageman factor and Kallikrein through factors XII, IX, VIII

Question 13

What is the extrinsic coagulation pathway?

Answer 13

Tissue factor binding with factor VII

Question 14

What is the common pathway of coagulation?

Answer 14

Activated Factor IIa then through X, V, II

Question 15

What happens after the common pathway of coagulation?

Answer 15

Factors II and XIII activate fibrinogen to fibrin

Question 16

What type of vitamin is vitamin K and where is it stored?

Answer 16

Fat soluble in the liver

Question 17

What does vitamin K produce?

Answer 17

Clotting factors II, VII, IX and X

Question 18

What competes with vitamin K?

Answer 18

Warfarin

Question 19

What is plasmin?

Answer 19

Clot buster

Question 20

What are anti-clotting factors?

Answer 20

Protein S, protein C and antithrombin II

Question 21

What causes inherited disorders of coagulibility?

Answer 21

Protein C/S/antithrombin II deficiency or Factor V Leiden

Question 22

Why are thrombi less common in arteries?

Answer 22

High flow blood moves pro-coagulant material away quickly

Question 23

When is the only occasion that thrombosis occurs in arteries?

Answer 23

Atherosclerosis

Question 24

Why are sites where vessels branch more common?

Answer 24

More turbulent blood flow

Question 25

Where is stasis common?

Answer 25

Depp veins, faulty valves and venous insufficiency

Question 26

Where do the biggest PEs tend to come from?

Answer 26

Femur

Question 27

Most emboli are thrombi, what else could they be?

Answer 27

Gas, fat, foreign bodies, tumour clumps

Question 28

Pulmonary emboli are an important cause of what?

Answer 28

Sudden death and pulmonary hypertension

Question 29

Where is the source of most PEs?

Answer 29

Deep vein thrombosis

Question 30

What is ischaemia?

Answer 30

Insufficient blood flow

Question 31

What is infarction?

Answer 31

Tissue death as a result of ischaemia

Question 32

What do large emboli cause?

Answer 32

Death, infarction, severe symptoms

Question 33

What do small emboli cause?

Answer 33

Pulmonary hypertension but clinically silent

Question 34

What is pulmonary infarction?

Answer 34

Compromised blood and oxygen causes lung tissue to die

Question 35

How does a DVT present?

Answer 35

Hot, swollen, red, tender calf or whole leg

Question 36

What is the 1st line scan for DVT?

Answer 36

Ultrasound Doppler leg scan

Question 37

What is the 2nd line test for DVT?

Answer 37

CT of ileo-femoral vein, IVC and pelvis

Question 38

How will a large PE present?

Answer 38

CV shock, low BP, central cyanosis, sudden death

Question 39

How will a medium PE present?

Answer 39

Pleuritic pain, haemoptysis, breathless

Question 40

How will a small PE present?

Answer 40

Progressive dyspnoea, pulmonary hypertension, right sided heart failure

Question 41

What are risk factors for PE?

Answer 41

Thrombophilia, contraceptive pill, pregnancy, pelvic obstruction, trauma, surgery, immobility, malignancy, vasculitis, obesity

Question 42

What are clinical features of PE?

Answer 42

Tachycardia, tachypnoea, cyanosis, fever, low BP, crackles, rub, pleural effusion

Question 43

What will ABGs for PE show?

Answer 43

Low O2- type 1 respiratory failure

Question 44

What will a CXR of PE show?

Answer 44

Normal early on, may show a wedge shaped infarct

Question 45

What is the gold standard test for PE?

Answer 45

CTPA

Question 46

What is the 2nd line scan for PE which is good in pregnancy?

Answer 46

V/Q scan

Question 47

What is a useful rule out test for PE?

Answer 47

D-dimers

Question 48

What are some ways a DVT can be prevented?

Answer 48

Compression stockings, early post-op mobilisation calf muscle exercise, anticoagulants

Question 49

What are PEs treated with and for how long?

Answer 49

Anticoagulation with LMWH or warfarin for 3 months is provoked and longer if not

Question 50

What is the treatment for large life threatening PEs?

Answer 50

Thrombolysis

Question 51

What are interactions of thrombolysis?

Answer 51

Alcohol, antibiotics, aspirin, NSAIDs, grapefruit

Question 52

What can post-thrombotic syndrome cause?

Answer 52

Pain, oedema, hyperpigmentation, eczema, varicose veins, ulceration

Question 53

What is the relative flow/pressure in the pulmonary circulation?

Answer 53

High flow, low pressure

Question 54

What is classed as pulmonary hypertension?

Answer 54

>25mmHg

Question 55

What can cause pulmonary venous hypertension?

Answer 55

Ischaemia, stenosis, cardiomyopathy

Question 56

What can cause pulmonary arterial hypertension?

Answer 56

Hypoxia, multiple PE, vasculitis, drugs, HIV, left to right shunt

Question 57

What is cor pulmonale?

Answer 57

Right sided heart failure secondary to lung disease

Question 58

What are signs of cor pulmonale?

Answer 58

Central cyanosis, oedema, raised JVP, right ventricular heave

Question 59

What are probably the most important tests for Cor Pulmonale?

Answer 59

ECG, CXR, ABGs, echo

Question 60

How is primary pulmonary hypertension diagnosed?

Answer 60

By ruling out other causes

Question 61

What is the typical presentation of pulmonary hypertension?

Answer 61

SOB on exertion and signs of right sided failure

Question 62

What is treatment for primary pulmonary hypertension?

Answer 62

Pulmonary vasodilators and lung transplant