Venous Thromboembolic Dz (PE/DVT)

Question 1

What is virchow’s triad?

Answer 1

endothelial damage, venous stasis, hypercoagulable state

Question 2

Why suspect thrombophilia? Which labs for initial work-up?

Answer 2

• previous VTE, famhx, hx of multiple miscarriages, no recent trauma/malig/estrogens/pregnancy
• CBC, CMP, PT, PTT (set aside blood for ATIII, Protein C/S)
• Later: Factor V Leiden, hyperhomocysteinemia, anti-phospholipid Ab

Question 3

What is a person’s risk if first episode with no RF or fmhx?

Answer 3

low- no investigations

Question 4

What is person’s risk if >50yo, idiopathic first episode, no fmhx?

Answer 4

moderate-

1. resistance to activated protein C
2. Prothrombin mutation
3. Lupus anticoag
4. ELISA for antiphospholipid Ab
5. Homocysteine level

Question 5

What is risk if idiopathic before age 50 or recent thrombosis or fmhx of VTE?

Answer 5

high
(everything for moderate + ATIII)
protein C/S

Question 6

What are signs of UE DVT?

Answer 6

-SVC syndrome, blurred vision, dyspnea (causes include trauma from sports or med instruments), thoracic outlet syndrome- Adson test and Wright test

Question 7

What are signs of DVT in general?

Answer 7

• tenderness, erythema, warmth, edema, low grade fever, +Homan, +Moses

Question 8

What tests are used in dx DVT?

Answer 8

D-dimer, duplex US, contrast venography is gold standard

for UE and pelvic=MRI

Question 9

How do you treat DVT in general?

Answer 9

SQ LMWH- loveox
IV or SQ UFH
SQ fondaparinux
*Start warfain at same time

Question 10

What is goal PTT with heparin? What is goal INR with coumadin?

Answer 10

1. 5-2.3

2. 0-3.0

Question 11

How do you reverse OD of heparin? coumadin?

Answer 11

• protamine

- takes time and requires FFP if urgent

Question 12

What are some special cases for tx of DVT?

Answer 12

• UE in young: tPA infusion, mechanical fragmentation via cath
• IVC filter if no anticoag or recurrent or bleeding risk

Question 13

What is prophylaxis for DVT for high risk? Low risk? When is LMWH preferred?

Answer 13

• SQ heparin or LMWH for (CHF, resp illness, immobilization, hx VTE, major sx (for 1 mo after sx))
• IPCs or SCDs
• orthopedic cases

Question 14

What type of cardiac complications happen with PE?

Answer 14

• RV pressure inc–>dilation, hypokinesis, tricuspid regurg

- Compress RCA–>subendocardial ischemia

Question 15

What are the sxs of PE?

Answer 15

dyspnea and pleuritic CP, tachycardia, low O2 sat

anginal if ischemic, hemoptyis if pulm infarct, syncope if cor pulmonale

Question 16

How do you dx PE?

Answer 16

1. V/Q scan
2. Spiral CT w/ contrast
3. echo
4. pulmonary angiography

Question 17

How do you tx PE?

Answer 17

1. admit to hospital
2. antigoag w/ heparin and warfarin (for 3-6 months, longer in cancer)
3. tPA if hypotensive/shock/RVE
   if tPA contraindicated in massive PE, consider sx or percutaneous removal
4. EKOS

Question 18

What is cor pulmonale?

Answer 18

RHF d/t idiopathic PHTN–> dec CO, arrhythmias

Question 19

What are other types of emoblic phenomena?

Answer 19

septic, myxoma, parasites, amniotic fluid, fat, air

Question 20

Cause of septic emoblism?

Answer 20

infective endocarditis, usually strep viridans- cause vegetations on valves that break off- takes 2 weeks to 6 months or more

Question 21

Symptoms of septic embolism? How to tx?

Answer 21

• back pain, fever, heart murmur, pleuritic CP, hemoptysis, sore throat, swelling of jaw, bacteremia
• CXR round cavitating infiltratrates
• IV PCN 24 million units/day + metronidazole 500 mg q 6 hrs

Question 22

What is an atrial myxoma?

Answer 22

• primary cardiac tumor, familial
• dx on echo
• tx is sx

Question 23

What is an amniotic fluid embolism?

Answer 23

fluid is foreign= clotting => massive obstruction of microvasculature=> shock=> DIC (tx is supportive)
-mortality is 80% maternal

Question 24

How does a fat embolism occur?

Answer 24

usually after bone fracture (12-36 hrs)

-mental aberrations, delerium, coma, dyspnea, tachypnea, tachycardia, anemia, thrombocytopenia

Question 25

What are the two events in fat embolism? Tx?

Answer 25

1. release of free fatty acids–> toxic vasculitis–> plt-fibrin thrombosis
2. Obstruction of small pulm aa by macroaggregates of fat
   Tx is supportive= high mortality

Question 26

What are types of parasitic embolism?

Answer 26

• ecinococcus granulosus- liver cyst

- filarial parasites, strongyloids, ascaris go to pulm circ

Question 27

How does an air embolism happen?

Answer 27

• trauma, sx, injection
• large may cause infarction so place pt on left side to trap air in RA/V, place pt in trendelenberg to remove central lines