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cvs > Venous Disease + Pulmonary Embolism > Flashcards

Venous Disease + Pulmonary Embolism Flashcards

1
Q

What is a venous thrombus

A

Fibrin and red cells

Develops in areas of stagnant blood causing back pressure

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2
Q

What is an arterial thrombus

A

Fibrin and platelets

Causes ischaemia and infarction

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3
Q

What causes a venous thrombus

A

Stasis
Hypercoagulable
Vessel damage

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4
Q

What makes VTE unlikely

A

If on anti-coagulation

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5
Q

What are the symptoms of a DVT

A 
Leg swelling - measure diff in calf circumference as well as swelling 
Calf tenderness
Pitting oedema 
Warmth
Erythema
Prominent veins 
Mild pyrexia 
Tachycardia
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6
Q

What is differential of DVT

A

Gout
Popliteal cyst
Arthiritis

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7
Q

What are the RF for DVT split into general, underlying, drug

What is high risk surgery

A 
Age
Obesity
Immobility e.g. bed rest / long haul flight
Trauma
Post op - pelvic / orthopaedic 
Pregnancy - up to 6 weeks post partum
Varicose veins 
PMH
FH

Underlying

  • Malignancy - pelvic
  • HF
  • Nephrotic
  • Heritale thrombophilia- Factor V leiden / anti-phosphoplipid
  • Polycythaemia
  • Sickle cell

Drug

  • HRT
  • OCP
  • Tamoxifen
  • Anti-psychotic
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8
Q

How do you investigate suspected DVT

A 
Well's score
If low risk = D-dimer
If D-dimer -ve can exclude DVT 
If high risk or +ve D-dimer = doppler USS
If USS +Ve = treat as DVT
If USS -ve = can exclude DVT
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9
Q

What does Wells look at

A 
Paralysis / immobilisation >3 days
Active cancer
Surgery >12 weeks
Tenderness 
Enitre leg swollen
Calf >3cm asymptomatic
Pitting oedema
Collateral superficial veins
Previous DVT
Another Dx more likely = -2
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10
Q

How do you treat DVT and how do you monitor

A 
SC LMWH for 5 days or until INR 2-3 
Unfractioned heparin - used in renal failure 
Give if delay in USS / Dx
APTT to monitor 
Anti-coagulation for 3 months 
- Warfarin
- DOAC
-
Or through cancer / pregnancy
If clot idiopathic / low risk of bleeding continue for longer
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11
Q

How do you prevent DVT

What is preferred in orthopaedic surgery

A

TED stockings
Early mobilisation
Daily LMWH injections to all immobile patients
Fondaparinux (factor Xa inhibitor) decrease risk of DVT over LMWH in major ortho surgery

Stop OCP / HRT before surgery (4 weeks)

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12
Q

When ae graduated compression stockings indicated

A 
Chronic venous insufficiency 
Varicose
Oedema
Post-phlebetic
Not to treat DVT
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13
Q

What is post phlebitis / thrombotic syndrome and how do you manage

A 
Chronic venous insufficiency after DVT due to hypertension
Swelling
Discomfort
Heavy calf
Itch 
Pigmentation
Varicose vein
Ulceration
Manage with compression stockings
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14
Q

What is a D-dimer and what else is it raised in

A

Breakdown product
Sensitie marker of thrombus but not specific
Also raised in malignancy / HF / renal / infarction / sickle / surgery / trauma so not reliable
e.g. PE common after hip fracture but D-dimer will be raised post-trauma / surgery

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15
Q

What causes PE

A 
DVT - usually in proximal femoral or iliac 
50% idiopathic and 50% underlying cause
Rarely
RV thrombus post MI
Septic emboli R side IE
Fat / air / amniotic fluid
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16
Q

What are the symptoms

A 
Pleuritic chest pain
Sudden onset SOB + no chest signs = think PE 
Cough
Haemoptysis
Hypoxia
Dizzy / syncope
Tachycardia
Tachypnoea
Pleural rub
Crackles
Fever
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17
Q

What are signs of massive PE

A 
Severe SOB and tahcy
Pleural effusion
Dullness on percussion
Collapse due to drop in CO 
Cyanosis
Low BP
Raised JVP
Altered heart sounds - 4th HS
Cardiac arrest
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18
Q

How do you Dx PE

A

FBC, U+E, clotting
CXR to exclude other cause (enlarged artery / decreased vascular) - always order first
ECG
ABG - alkalosis due to hyperventilation (pH normal due to anaerobic respiration buffering) but low O2 (hyperventilation due to anxiety = high O2)
Calculate Geneva

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19
Q

What does Geneva score look at

A 
S+S DVT
Other Dx unlikely
Tacycardia
Surgery
Previous
Active cancer
Haemoptysis
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20
Q

If moderate or high risk what happens

A

CTPA or V/Q scan

No place for D-dimer

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21
Q

When would you do V/Q

A

Pregnancy
Renal failure
Allergy to contrast

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22
Q

What do you do if low risk

A

D-dimer

If high = CTPA

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23
Q

How do you treat VTE

A

Oxygen if hypoxic
Thrombolysis = 1st line if circulatory failure e.g. hypotension
DOAC = 1st line for 3 months
If low risk of bleed can continue for longer or if malignancy
Shorter if on anti-platelet / bleeding risk
LMWH if delay in Dx or if using warfarin as takes a few days till INR 2-3
LMWH for 6 months if proven malignancy

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24
Q

What should INR be

A

2-3

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25
Q

What do you do for idiopathic clot

A 
Stay on for longer as higher risk of another as prone
Hx and exam
CXR
FBC, Ca, LFT, urine dip 
Do all of these

Consider
CT CAP / mammogram etc
Haematology for thrombophilia screen

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26
Q

What do you do for massive PE

A

Thrombolyse = 1st line

Vena cava filter if recurrent / active bleeding

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27
Q

What are complications

A

Pulmonary haemorrhage / infarction = pleural rub and pleuritic pain
Hypertension
RHF

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28
Q

What are ECG changes

A

Sinus tachy
RH strain - RBBB, V1+V2, T wave inversion
S1,Q3, T3
Deep S, pathological Q and inverted T

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29
Q

When are DOAC CI

When is LMWH CI

A

Pregnant
Breast fed
Malignancy

LMWH CI if already on warfarin / DOAC / active bleeding

30
Q

Why are you SOB in PE

A

V/Q mismatch

Shunt created

31
Q

What is varicose veins and what causes varicose veins

A

Dilated torturous superficial veins
Valves to prevent back flow = damaged
Proximal obstruction or weakness damages valves
Blood flows back from deep veins into superficial veins which become dilated and engorged leading to more damage and increased pressure
DUE TO INCREASED PRESSURE
Occurs at sapheno-famoral and sapheno-popliteal junction

32
Q

What are the symptoms and complications

A 
Discomfort
Burning
Nocturnal cramps
Swelling
Tightness
Discolouration
Haemorrhage as fragile skin over veins
Superficial thrombophlebitis 
Pruritus
Spider veins - no Rx
Haemosiderin, lipodermatosclerosis, venous eczema 
Venous ulcers
Non-pitting oedema

Increased risk of infection, ulcers, and DVT

33
Q

What are RF / 2 causes

A

2 obstruction - DVT / pregnancy / pelvic tumour
AV malformation
Congenital valve absence = rare

RF = increase pressure 
Standing 
Twins
Multiple pregnancy 
Pelvic tumour 
Prengnacy 
Previous DVT
OCP
Trauma
FH
34
Q

How do you investigate

A

Duplex USS to look for site
Check deep venous system competent before removal - if DVT = incompetent
+Ve Trendelenburg
ABPI to exclude PAD

35
Q

How do you treat

A

Conservative

  • Lose weight
  • Education e.g. avoid standing
  • Graduated compression stockings
  • Skin care

Surgery
Endovenous = 1st line (cannulate vein pass catheter and heat + laser to fibrose)
USS guided sclerotherapy = 2nd line
Open Surgery - strip vein under Ga = 3rd line
Compression stockings if pregnant

36
Q

When is open surgery CI

A 
DVT as need deep venous to compensate
Pregnancy 
Comorbid
Arterial insuffiency
Obesity
37
Q

When is intervention indicated

A 
Superficial thrombophlebitis
Symptomatic varicose veins
Chronic venous insuffieincy
Superficial vein thrombosis
Leg ulcer 
Bleeding
Anxiety
Cosmesis
38
Q

What are complications of surgery

A 
Haemorrhage
Thrombophlebitis
Wound
Saphenous nerve damage
DVT
39
Q

What does chronic venous insufficiency affect

A

Deep veins

40
Q

What causes chronic venous insufficiency

A

Venous hypertension creates back pressure
Due to failure of muscle pump
or Obstruction

41
Q

What causes failure of muscle pump

A 
Venous reflux 
Obstruction - DVT 
Neuromuscular
Obesity 
Inactive
42
Q

Superficial vein

A

Varicose

43
Q

Deep vein

A

DVT

44
Q

What are symptoms of chronic venous insufficiency

A

Ankle oedema as veins leaky and blood leaks out
Telangtasia
Venous eczema as skin becomes dry and inflamed
Hemosiderin pigmentation - brown (HB breaks down and deposited)
Hyperpigmentation
Lipodermatosclerosis as skin becomes tight and fibrotic
Venous ulceration >4 weeks
Warm

45
Q

How do you Dx chronic venous insufficiency

A

History and examination
ABPI - calculate as if arterial compression would damage
Duplex to check flow of vein = 1st line

46
Q

How do you treat

A 
Elevate 
Manual drainage
Compression stockings or bandage 
Naproxen = 1st line for superficial thrombophlebitis 
Dressing
Eczema creams 
Physio/ OT
Exclude DVT
47
Q

What do you not give in chronic venous insufficiency

A

Diuretic

48
Q

What causes lymph oedema

A 
Inadequate drainage of lymphatic system 
Congenital - presents in first 3 decades 
Malignancy
Surgery - after LN clearance 
RT
Infection
Post DVT
49
Q

How do you treat

A 
Prone to infection / ulcers / venous failure 
Massage 
Elevation
Manual drainage
Compression
50
Q

What causes venous ulcers

A

Hypertension 2 to chronic venous insufficiency

51
Q

What are the symptoms

A 
Painless 
Large and irregular 
Other features of insufficiency
Above ankle
Affect gaiter region 
Shallow ulceration
52
Q

How do you Dx

A

Duplex USS
ABPI to exclude arterial
Biopsy if non-healing to exclude malignancy / Marlins ulcer

53
Q

How do you Rx

A 
Refer to venous ulcer clinic 
Managed by district nurses 
Good wound care - debride, clean, dress
Manage RF 
Best rest and elevation 
Compression after excluding PAD 
Tissue viability nurse 
Plastic surgery 
Refer if >12 weeks or >10cm for skin graft
54
Q

Arterial ulcers

A 
Toes and heels
Painful
Gangrene
Cold
No pulse
Pain at night when legs elevated 
Tend to be smaller with more regular border 
Low ABPI
55
Q

Neuropathic ulcers

A

Plantar surface of metatarsal and hallux
Due to pressure
Shoes to prevent

56
Q

Pyoderma gangrenosum and what is Rx

A

IBD / RA
Erythematous nodules or pustules which ulcerate
Rx = steroid

57
Q

Marjolin’s ulcer

A

SCC at site of chronic inflammation e.g. OM / burns after 10-20 years
Mainly lower limb

58
Q

Vein anatomy

A 
IVC
Common iliac
Internal iliac
External iliac
Femoral
Popliteal 
Arterial and posterior tibial 
Long saphenous (superficial) -> femoral (arise dorsal venous arch and travel anterior to medial malleolus) 
Short saphenous -> popliteal (arise plantar venous arch and posterior to lateral malleolus)
59
Q

What nerve close to superficial veins

A

Sural

60
Q

Do superficial veins have muscle pump

A

No only deep veins

Deep veins are within muscle so can withstand higher pressure

61
Q

What are the 3 tests to Dx chronic venous insufficiency

A

Tap test
Hand held doppler
Trendelenburg

62
Q

What is the tap test

A

One hand on saphenofemoral junction
One on long saphenous above knee
Tap junction
If transmits =.incompetence

63
Q

What is the hand held doppler

A

Put your hand over junction
Squeeze calf
Single whoosh if competent
Double if reflux back

64
Q

What is the trendelenburg test

A

Drain superficial by lying flat and raising legs
Apply pressure over junction
Stand up
If don’t dilate = vein competent
If dilate even with pressure = incompetent

65
Q

What are veins that you can remove without affecting patient

A

Renal as collateral adrenal and gonadal tae over
IVC
Facial - transected in carotid endarectomy

66
Q

How could a DVT cause systemic ischaemia

A

If DVT passes into heart and patient has a VSD allowing blood clot to move into L side of heart and into systemic circulation
COMMON EXAM

67
Q

What should everyone in hospital get

A

VTE risk assessment

68
Q

If increased risk what do they get

A

LMWH
Caution in renal failure
If CI i.e. due to risk of bleed = compression stockings

69
Q

When does great saphenous join deep system (femoral vein)

A

3cm below and lateral to pubic tubercle

70
Q

Where does small saphenous join deep (popliteal)

A

Popliteal fossa

cvs (30 decks)

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