Venous Thrombo Embolism (VTE) = (DVT + PE)

Question 1

What is hemostasis?

Answer 1

Arrest of bleeding; the1st step of wound healing.

Question 2

What are the 4 Steps of hemostasis?

Answer 2

Vessel injury
Vascular spasm
Platelet plug
Primary hemostasis
Coagulation
Secondary hemostasis

Question 3

Describe the main features of Thrombocytes (Platelets)?

Answer 3

Small fragments of megakaryocytes
Formation is regulated by thrombopoietin
Platelets contain granules that are secreted in response to “activation”
Important in preventing blood loss
Platelet plugs
Promoting formation and contraction of clots

Question 4

What are normal and abnormal thrombocyte count levels?

Answer 4

Normal: 150 to 400 x 10^3/mm3

Question 5

What are therapy considerations for thrombocytopenia between 50,000 and 140,000?

Answer 5

low intensity progressive resistive exercise (PRE) and aerobic exercise (none to minimal elevations/ resistance)

Question 6

What are therapy considerations for thrombocytopenia betweeen 30, 000 – 50, 000?

Answer 6

(typically not associated with spontaneous bleeding.) AROM exercise, walking ad lib

Question 7

What are therapy considerations for thrombocytopenia between < 10, 000 – 20, 000?

Answer 7

Risk of spontaneous bleeding, petechia, ecchymosis and prolonged bleeding time.
Therapy may be contraindicated/ minimal AROM
No brushing of teeth

Question 8

What are therapy considerations for Thrombocytosis ?

Answer 8

(elevated values) Thrombocytosis: > 400 x 103/ mm3. No distinct recommendation; note paradoxical increased risk of bleeding.

Question 9

What is Venous Thromboembolism (VTE)?

Answer 9

disease that includes both deep vein thrombosis (DVT) and pulmonary embolism (PE)

3rd most common cardiovascular illness
acute coronary syndrome (ACS) & CVA ; ~ 2/3 associated with hospitalization

Question 10

what is the prevalence of VTE?

Answer 10

PE remains the most common preventable cause of hospital death, accounting for up to 10% of hospital mortality1

DVT/PE is much more common in the hospitalized patient (surgical and medical2) compared to those living in the community

Question 11

Why should outpatient PTs be concerned about VTE?

Answer 11

Because there is a growing number of cases of VTE in patients who were recently hospitalized, and who she outpatient PTs.

Question 12

What is Virchow’s Triad?

Answer 12

1858, RudolphVirchowfamously proposed that the alteration of one of the three characteristics of venous circulation may precipitate a thromboembolic event.
3 characteristics:
(1) venous stasis
(2) activation of blood coagulation, and
(3) vein damage

Question 13

What are the statistics for inpatients and risk factors for VTE?

Answer 13

almost all have 1 RF, 40% have 3 or more RFs.

Question 14

What are the Primary VTE Risks in Hospitalized Patients?

Answer 14

Increasing age,Cancer, Pregnancy 60/100,000 women, Immobility, Surgery, Hormone replacement therapy / OCP’s
10-30 / 100,000 users vs 4-8/100,000 non-users
Thrombophilic disorders

Question 15

What is now recommended beyond risks from the Well’s criteria?

Answer 15

1st thing done is a D-dimer test, which looks for fibrin –> clotting factor –> very sensitive for a blood clot somewhere in the body. Also look for Dyspnea, pleuritic pain, tachypnea, dyspnea and chest pain.

Question 16

What is Homan’s sign, and what does it say about VTE?

Answer 16

palpate calf and dorsiflex. Found to not be sensitive.

Question 17

What are mechanical prophylaxes for VTE?

Answer 17

Graduated compression stockings (GCS)

Intermittent pneumatic compression (IPC)

Question 18

What are some medical prophylaxes for VTE?

Answer 18

Unfractionated Heparin (UfH)
Low Molecular Weight Heparin (LMWH)
Warfarin (Coumadin©)
Aspirin
Fondaparinux (Arixtra©)

Question 19

Why do mechanical prophylaxes for VTE?

Answer 19

Multiple studies have shown benefit to reduce risk of DVT
less effective than medical prophylaxis (adjunct)
Must be worn continuously
May reduce tissue oxygenation (risk in PVD population)
Need to be sized and fitted properly
No bleeding risk

Question 20

What are contraindications for putting pts on anticoagulation ?

Answer 20

Active bleeding or high bleeding risk
History of heparin-induced thrombocytopenia
Platelet count <100,000
Already receiving oral anticoagulants or platelet inhibitors
Abnormal creatinine clearance rate

Question 21

what is one histological mechanism behind mechanical compression?

Answer 21

If reduce size of vein, you increase venous pressure, and may actually improve valve function. Pressure causes release of protein called tissue factor inhibitor. So kind of cool mechanism.

Question 22

What is measured when pt is on Heparin?

Answer 22

PTT: Partial Thromboplastin Time.
Normal: 21-35 seconds
Therapeutic endpoint: 1.5-2.5 times control
Goal: 46-70 seconds

Question 23

What is measured when pt is on Coumadin (Warfarin)?

Answer 23

PT: Prothrombin Time
INR:  International Normalized Ratio
 Normal:  PT: 11 -13 sec; INR 1
Therapeutic endpoint: 2-3 times control
Goal may be higher if recurrent VTE or mechanical valve (2.5-3.5)

Question 24

What is the American Heart Association recommendation for the INR to prevent risk of Ischemic or hemorrhagic stroke?

Answer 24

between 2 and 3.

Question 25

What are major complications to VTE?

Answer 25

Venous stasis syndrome (ie, post-thrombotic syndrome)
Venous ulcer, and
Chronic thromboembolic disease/ Pulmonary hypertension ( means they are constantly throwing clots)

Question 26

What % of pts will develop Post Thrombotic Syndrome (PTS) and in what time frame?

Answer 26

Develops in 20% - 50% of patients within 1-2 years

Question 27

What is a major complication of Post Thrombotic Syndrome (PTS)?

Answer 27

Severe PTS results in venous stasis ulcers

~ ¼ to ⅓ of PTS

Question 28

What are common symptoms of Post Thrombotic Syndrome (PTS)?

Answer 28

Pain; heaviness; cramps; itching; tingling
Aggravated by standing/ walking
Physical exam:
Edema; hyperpigmentation; telangiectasias; varicosities

Question 29

What are risk factors for Post Thrombotic Syndrome (PTS)?

Answer 29

Proximal DVT
Recurrent DVT
Prolonged symptoms (> 1 month post event)
Obesity
Inadequate &/ or delayed anticoagulation

Question 30

Is there evidence to support walking patients while wearing compression garments if they have an acute proximal DVT?

Answer 30

Yes, resolution of pain and swelling is faster compared to patients on bed rest, clot size also decreased. Early ambulation is safe and effective, but check institution guidelines.