Venous Thrombo-Embolic Disease

Question 1

Where do DVTs most commonly form?

Answer 1

Anterior Tibial 
Posterior Tibial
Perineal
Superficial Femoral
Popliteal

Question 2

What are risk factors for DVT?

Answer 2

Age
Pregnancy/COCP
Trauma
Surgery
Past DVT
Cancer
Obesity
Immobility
Thrombophilia

Question 3

What is the Well’s score?

Answer 3

Pretest clinical probability score for DVT
Based on common symptoms
>2 makes DVT/PE likely

Question 4

What are the common symptoms of a DVT?

Answer 4

Calf Sx
-warmth
-tenderness
-swelling
-ertythrema
Fever
Pitting oedema

Question 5

What is the D-dimer test?

Answer 5

D-dimers are increased in clotting patients

NOT SPECIFIC FOR DVT

Question 6

What other clinical conditions could be included in the DDx for pain/swelling of the lower limb?

Answer 6

DVT
Superficial thrombo-phlebitis
Chronic venous insufficiency
Cellulitis
Acute arterial ischaemia
Hyperprotinaemia

Question 7

Describe Superficial thrombo-phelibitis

Answer 7

Inflamed vein near the surface of the skin (caused by clot)
Lumps under skin, NOT swelling of whole calf
Cold flannel over vv will reduce pain

Question 8

Describe Chronic venous insufficiency

Answer 8

Blood pools in legs due to damaged valves in vv
Elevated BP in vv
Leathery skin
Stasis ulcers

Question 9

Describe Cellulitis

Answer 9

Infection of deeper layers of skin/tissue
Skin becomes red, hot, swollen, painful, tender
High temp, vig shaking before
N/V

Question 10

Describe Acute Limb Ischaemia

Answer 10

Acute thrombotic occlusion leading to extensive tissue necrosis (<6hrs)
Pre-existing arterial disease common
6 P's
-pale
-pulseless
-painful
-paralysed
-paraesthetic
-perishingly cold

Question 11

Describe hyperprotinaemia

Answer 11

High blood protein
Leads to peripheral oedema
Tends to be painless/

Question 12

How can the DDx for leg pain/swelling be narrowed down? - History?

Answer 12

Rapid/acute onset?
Symptoms beforehand?
Pre-existing conditions?
Associated symptoms?
Painful/not painful?

Question 13

How can the DDx for leg pain/swelling be narrowed down? - Examination?

Answer 13

Unilateral/bilateral
Fluid based swelling?
Tender?
Cracked/dry skin?
Reddened?
Temperature?

Question 14

How can the DDx for leg pain/swelling be narrowed down? - Investigations?

Answer 14

Urinalysis (proteinuria)
FBC (infection/inflammation)
Clotting screen
CXR
D-dimer test (clotting)
Ultrasound
ECG/Echo

Question 15

What imaging modalities are used to investigate suspected DVT?

Answer 15

CXR - look for pulmonary oedema/emboli
Echo - look for heart failure
Ultrasound/CT - haematoma
CT angiography

Question 16

What are the clinical features of PE?

Answer 16

Breathlessness (acute)
Pleuritic pain
Haemoptysis
Syncope
Pyrexia
Tachypnoea
Pleural effusion
Hypotension

Question 17

What does the severity of PE depend on?

Answer 17

Depends on size/number/distribution

-small often asymptomatic, large fatal

Question 18

Describe the pathology of a PE

Answer 18

Usually arising from a venous thrombus in pelvis/legs

Clots break off - pass through venous system - R heart - pulmonary circulation

Question 19

What are some less common causes of a PE?

Answer 19

Right ventricular thrombus (post MI)
Septic emboli (RHS endocarditis)
Fat/Air/Amniotic fluid emboli
Neoplastic cells
Parasites

Question 20

What are the complications of DVT?

Answer 20

Deep venous insufficiency
PE
Post thrombotic/post phlebitic syndrome

Question 21

What is post-thrombotic syndrome?

Answer 21

Chronic venous HTN developing after a DVT (20-40%

Question 22

What are the sx of post-thrombotic syndrome?

Answer 22

Pain
Swelling
Hyperpigmentation
Dermatitis
Ulcers
Gangrene
Lipodermatosclerosis

Question 23

How should DVTs be investigated?

Answer 23

D-dimer
Compression USS (non-collapsing veins)
Thrombophilia screen

Question 24

How should DVTs be managed?

Answer 24

Mobilise pts early
Heparin for immobile pts
Stop COCP
Use compression hosiery
LMWH AND warfarin, stop LMWH when INR 2-3

Question 25

What are the main three types of PE?

Answer 25

Massive PE (5%)
Major PE (10%)
Minor PE (85%)

Question 26

Describe massive PE

Answer 26

> 60% pulmonary circulation blocked, rapid cardiovascular collapse

Question 27

Describe major PE

Answer 27

Middle sized arteries blocked, causing breathlessness, pleuritic pain and haemoptysis

Question 28

Describe minor PE

Answer 28

Small peripheral vessels blocked, pts asymptomatic or present as major PE

Question 29

How should PEs be managed?

Answer 29

Minor/Major PE as per DVT
Massive PE
   -A-E resuscitation
   -IV morphine & antiemetic
   -LMWH
   -warfarin (if SBP >90)
   -vasopressors (if SBP <90)