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clin med final > Venous Thromboembolism > Flashcards

Venous Thromboembolism Flashcards

1
Q

what are the most common presentations of venous thrombosis

A
  • deep venous thrombosis
  • pulmonary embolism
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2
Q

venous thromboembolism pathogenesis: Virchow’s triad

A
  1. stasis: alterations in blood flow
  2. vessel wall injury
  3. hypercoagulability
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3
Q

what are some acquired risk factors (chronic conditions) for VTE

A
  • malignancy
  • antiphospholipid antibody syndrome
  • myeloproliferative disorders
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4
Q

what is a major risk for VTE

A

previous thrombotic event

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5
Q

what are some acquired risk factors (transient states) for VTE

A
  • surgery
  • trauma
  • immobilization
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6
Q

what are some acquired risk factors (female specific) for VTE

A
  • pregnancy
  • hormonal contraceptives
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7
Q

what are the most common inherited risk factors for VTE

A
  • Factor V Leiden mutation
  • Prothrombin gene mutation
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8
Q

What is the pretest probablity scoring system for VTE

A

Wells criteria

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9
Q

clinical presentation of DVT

A
  • can be asymptomatic
  • affected area may have
    • swelling
    • pain
    • warmth
    • redness or discoloration
    • palpable cord (thrombosed vein)
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10
Q

homan’s sign

A
  • positive sign: pain in the calf on forceful and abrupt dorsiflexion of the patient’s foot at the ankle when the knee is extended
  • **test has fallen out of favor
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11
Q

Name some important criteria in wells scoring

A
  • paralysis, orthopeding casting (1 point)
  • bedridden, major surgery (1 point)
  • tenderness (1 point)
  • swelling of entire leg (1 point)
  • calf swelling (1 point)
  • pitting edema (1 point)
  • cancer (1 point)
  • alternative diagnosis more likely than DVT (-2 points)
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12
Q

wells scoring (numbers showing probability)

A
  • 3-8 points = high probability
  • 1-2 points = moderate probability
  • -2-0 = low probability
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13
Q

D-dimer in detecting VTE

A
  • sensitive test but lacks speficity
    • only useful when negative
  • greater than 500 ng/mL in virtually ALL patients with VTE
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14
Q

is contrast venography recommended as initial screening in detecting VTE

A
  • not recommended as initial screening
  • invasive
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15
Q

what is the preferred test in the setting of recurrent DVT

A

impedance plethysmography

  • measures small changes in electrical resistance that reflect blood volume
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16
Q

what is the test of choice in detecting VTE

A

compression ultrasound

  • detects loss of vein compressibility
  • noninvasive, inexpensive
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17
Q

list steps you would take after getting a low probability wells criteria score

A
  1. D-dimer testing
    1. Negative: DVT ruled out
    2. positive: US
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18
Q

list steps you would take after getting a moderate or high probability wells criteria score

A
  1. US
    1. Positive: treat DVT
    2. Negative: D-dimer
      1. Negative: DVT ruled out
      2. Positive: repeat US in one week
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19
Q

treatment of DVT

A
  • anticoagulation
    • initial 5-10 days to protect from recurrent thrombosis
    • long term for minimum of 3 months
  • early ambulation
  • compression stockings
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20
Q

causes of superficial thrombophlebitis

A
  • venous cath or PICC line
  • spontaneous
  • hypercoagulability
21
Q

clinical presentation

  • dull pain in region or involved vein
  • induration
  • redness
  • edema of extremity is uncommon
A

superficial thrombophlebitis

22
Q

management of superficial thrombophlebitis

A
  • NSAID
  • generally subsides in 1-2 weeks
23
Q

what is the most common cause of pulmonary embolism

A

DVT

24
Q

how is PE classified

A
  1. hemodynamic stability
  2. temporal pattern (acute, chronic)
  3. anatomic location (saddle -> sub-segmental)
  4. symptoms (present or absent)
25
Q

hemodynamic instability classification

A

systolic blood pressure < 90 mmHg

  • **these patients are more likely to die from obstructive shoci
26
Q

Name the important signs and symptoms of PE

A
  • Dyspnea
  • pleuritic pain
  • cough
  • tachypnea
  • tachycardia
27
Q

97% of patients with PE had one or more of what 3 findings

A
  • dyspnea
  • pleuritic chest pain
  • tachypnea
28
Q

modified wells criteria for PE: what count signifies that PE is likely?

A
  • PE likely: > 4.0
  • PE unlikely < 4.0
29
Q

If you have determined “PE likely” what imaging should be done?

A

CT pulmonary angiogram

30
Q

what was the historical “gold standard” to diagnosis PE

A
  • pulmonary angiography
    • invasive
    • high IV contrast load
31
Q

when would a V/Q scan be used to detect a PE? What are the downfalls to it?

A
  • IV contrast allergy
  • renal dysfunction
  • sensitive but poorly specific (high # of false positives)
32
Q

classic findings on EKG in PE

A
  • sinus tachycardia
  • nonspecific ST-segment and T-wave changes
  • S1Q3T3 pattern
33
Q

what is the alternative to sensitive D-dimer testing in patients with a low probability assessment for PE

A

PERC rule: PE rule out criteria

  • if all 8 criteria are fulfilled, no further testing is required
34
Q

VTE anticoagulants options

A
  • IV unfractionated heparin (UFH)
  • SQ low molecular weight heparin (LMWH)
  • oral warfarin
  • factor Xa inhibitors
  • oral direct thrombin inhibitors
35
Q

initial therapy for the majority of patients with VTE

A
  • SQ LMW heparin
  • SQ fondaparinux (factor Xa inhibitor)
36
Q

initial therapy for the majority of patients with VTE in patients with severe renal failure and in those more likely to require rapid reversal of anticoagulation

A

IV UFH (unfractioned heparin)

37
Q

initial therapy for the majority of patients with VTE in pregnant patients and patients with malignancy

A

SQ LMW heparin

38
Q

long term therapy for VTE anticoagulation

A

warfarin

39
Q

what drug can be used to reverse anticoagulation after UFH and LMW heparin administration

A

protamine

40
Q

what drug can be used to reverse anticoagulation after warfarin administration

A

vitamin K and fresh frozen plasma

41
Q

what drug can be used to reverse anticoagulation after factor Xa inhibitors administration

A

nothing FDA approved

42
Q

what drug can be used to reverse anticoagulation after direct thrombin inhibitor administration

A

idarucizumab (Praxbind)

43
Q

duration of therapy for DVT if first episode

A
  • anticoagulation for a minimum of three months
  • provoked: persistent but reversible risk factors, extend anticoagulation until the risk factor is resolved
44
Q

duration of therapy for DVT if recurrent episode of unprovoked DVT, in particular those with proximal DVT

A

indefinite anticoagulation

45
Q

alternatives to anticoagulation (i.e. anticoagulation is contraindicated)

A

insert an IVC filter

  • prevents DVt from propagating to lungs
46
Q

function of thrombolytics. When is it used

A
  • activates plasminogen to form plasmin, resulting in the accelerated lysis of thrombi
  • used in unstable patients with PE
47
Q

function of thrombectomy/embolectomy

A

mechanical device to remove clots

48
Q

prophylactic measures to prevent DVT

A
  • sequential compression devices (SCD)
  • thromboembolic deterrent hose (TED)
  • low dose SQ UFH or SQ LMW heparin

clin med final (9 decks)

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