Thrombotic Disorders

Question 1

Deep veins in leg

Answer 1

Iliac, femoral, popliteal, tibial

Question 2

Superficial leg veins

Answer 2

Greater saphenous, lessor saphenous

Question 3

DVT

Answer 3

deep vein thrombosis

Question 4

Thrombotic risk factors

Answer 4

Post-op (orthopaedic)
Hospitalisation 
Pregnancy 
OCP
Long haul flights 
Cancer 
Obesity 
Drug abuse

Question 5

Presentation of DVTs

Answer 5

Unilateral calf swelling/ heat/ pain/ redness/ hardness
Cellulitis
Baker’s cyst
Muscular pain

Question 6

Doppler ultrasound

Answer 6

ultrasound transducer produces a real time 2D image of soft tissue structure
Colour duplex shows velocity and direction of blood flow
Veins are non-compressible by U/S probe

Question 7

Birchow’s triad of thrombosis

Answer 7

Circulatory stasis, hypercoagulable state, endothelial injury

Question 8

D dimer test

Answer 8

Likelihood of having a DVT can be assessed
Indicate activation of clotting cascade
Low wells score and negative d-dimer test have high negative predictive values

Question 9

Initial DVT treatment

Answer 9

Therapeutic anti-coagulation using sub-cat LMW (low molecular weight) heparin
Dosing done according to patients weight
If someone has renal impairment then anti-coagulate with IV unfractionated heparin

Question 10

Subsequent DVT treatment

Answer 10

Load patient with oral warfarin for 3-5 days

Stop LMW heparin once INR is over 2 for 2 days

Question 11

1st femoral/ iliac DVT

Answer 11

Secondary treatment: 6 months warfarin

Question 12

2nd DVT/PE

Answer 12

Treatment: lifelong warfarin

Question 13

Target INR

Answer 13

Between 2-3 (2.5)

Question 14

PE symptoms

Answer 14

Pleuritic pain
Dyspnoea
Haemoptysis

Question 15

PE on examination

Answer 15

tachycardia, tachypnoea, hypotensive

Question 16

Massive PE

Answer 16

Sycope, death

Question 17

CPTA

Answer 17

CT pulmonary angiogram

Question 18

Saddle embolism

Answer 18

Large pulmonary thrombo-embolism that straddles the main pulmonary arterial trunk at its bifurcation

Question 19

V/Q scans

Answer 19

Radio isotope shows under-perfusion (V/Q mismatch) due to PE

Indeterminate scans - can’t tell what the underlying cause is so rarely done

Question 20

ECG

Answer 20

Shows sinus tachycardia, atrial fibrillation, right heart strain

Question 21

Chest X-ray

Answer 21

Usually normal, shows linear atelectasis, small effusions

Question 22

PE outcomes

Answer 22

5% mortality with treatment 4% develop pulmonary hypertension
Leading cause of preventable death

Question 23

Treatment of massive PE

Answer 23

Thrombolysis and IV heparin

2-6% risk of serious bleeding

Question 24

Treatment of standard PE

Answer 24

LMW heparin injections (Tinzaparin)
Warfirin for 6 months
Inferior VC filters
Consider DOAC (NOACs) as alternatives

Question 25

LMW heparin better if

Answer 25

There is an underlying cancer

Question 26

Thrombophilia screen

Answer 26

Done in younger patients
Can be inherited:
Factor 5 leiden, prothrombin gene variant, anti-thrombin deficiency, protein C and S deficiency

Can be acquired from anti-phospholipid syndrome