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Clin Med Exam 4 (Lauren) > Venous Thromboembolism > Flashcards

Venous Thromboembolism Flashcards

1
Q

What are the 3 parts of Virchow’s triad?

A

Vessel wall injury

Hypercoagulability

Stasis

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2
Q

What are the “chronic” risk factors for VTE?

A

Malignancy

Antiphospholipid antibody syndrome

Myeloproliferative disorder

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3
Q

What are the “transient states” that are risk factors for VTE

A

Surgery

Trauma

Immobilization

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4
Q

What are the female specific risk factors for VTE

A

Pregnancy

Birth control

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5
Q

What are the most common “inherited” risk factors for VTE

A

Factor V Leiden mutation

Prothrombin gene mutation

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6
Q

What is the most useful finding when a patient presents with a DVT?

A

Larger calf diameter

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7
Q

What does a palpable cord mean?

A

Thrombosed vein

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8
Q

What are the 8 things in the DVT Wells score that are worth 1 point each?

A
  1. Paralyisis/orthopedic casting
  2. Bedridden/surgery
  3. Tenderness
  4. Swelling of entire leg
  5. Calf swelling
  6. Pitting edema
  7. Cancer
  8. Collateral non-varicose superficial veins
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9
Q

What is worth -2 points on the wells score?

A

Alternative diagnosis more likely than DVT

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10
Q

What wells score is considered a high probability for DVT?

A

3+

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11
Q

What is considered a positive D-Dimer?

A

Greater than 500ng/mL

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12
Q

Is d-dimer sensitive? Is it specific?

A

It is sensitive but not specific.

Therefore it is only useful when it is negative and you have a low climnical suspicion of DVT

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13
Q

What should your next step be if your patient has a high pretext probability for DVT?

A

Compression ultrasound

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14
Q

What was considered the historical “gold standard” for diagnosing a DVT?

A

Contrast venography

We don’t do it as an initial screening anymore because it’s invasive and expensive

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15
Q

What does a compression ultrasound look for?

A

Loss of vein compressibility, indicating a DVT

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16
Q

How do you do a compression ultrasound?

A

Push down with the transducer and watch for the vein to collapse, if it doesnt collapse you know you have a clot

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17
Q

What will Doppler ultrasound show you?

A

Blood flow

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18
Q

Which is more likely to embolize: a proximal DVT or one below the knee?

A

Proximal. Absolutely must treat

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19
Q

Are we trying to dissolve or remove the clot when we treat for DVT?

A

No

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20
Q

What is the goal of DVT treatment?

A

Prevent further cot propagation

Prevent PE

Decrease risk of recurrent VTE

Decrease complications

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21
Q

What is the mainstay of treatment for DVT?

A

Anticoagilaton

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22
Q

When should you start anticoagulation therapy once you’ve decided to treat a DVT?

A

Immediately and up to the first 10 days

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23
Q

What is the minimum amount of time someone should be on anticoagulant therapy?

A

3 months

Don’t EVER put someone on it and then take them off before 3 months

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24
Q

What is post-thrombotic syndrome?

A

Chronic venous insufficiency due to fucked up valves after a DVT

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25
Q

Should we use compression stockings to try to prevent post-thrombotic syndrome after a DVT?

A

Sure knock yourself out

No clear evidence that they really work though

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26
Q

What usually causes DVT in the upper extremity?

A

Placement of catheter/central line/pacemaker

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27
Q

What usually causes superficial thrombophlebitis?

A

Peripheral IV

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28
Q

Would you see swelling of the limb with superficial thrombophlebitis?

A

No

DVTs always cause swelling

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29
Q

What are the 4 ways you can classify a PE?

A
  1. Hemodynamics stability
  2. Temporal pattern (acute, chronic)
  3. Anatomic location
  4. Symptomatic/asymptomatic
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30
Q

What does a “massive” PE mean

A

Hemodynamics instability

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31
Q

What are the criteria for a “massive” PE aka one with hemodynamics instability?

A

Systolic BP less than 90

Or BP drop of 40mm for at least 15 min

32
Q

What is the most common presentation of PE

A

Shortness of breath followed by pleuritic pain

Cough

Symptoms from DVT

33
Q

What should you do if you have a pt with a suspected PE and they are hemodyanmically stable?

A

Wells score

D-dimer

Diagnostic imaging

34
Q

What is the imaging test of choice for a PE

A

CTPA

35
Q

If you suspect your pt has a PE and they are hemodynamically unstable, what should you do?

A

Just do an echo right there at the bedside to look for collapse of the RV -which would indicate PE

36
Q

What are the Wells criteria for PE?

A

Symptoms of DVT= 3 points

Something other than a PE is unlikely= 3 points

Heart rate over 100 = 1.5 points

Immobilization = 1.5 points

Previous DVT/PE = 1.5 points

Hemoptysis = 1 point

Malignancy = 1 point

37
Q

What score on the Wells criteria for PE would mean a PE is likely?

A

4.5 or higher

38
Q

What was the historical gold standard study for diagnosis of PE?

A

Pulmonary angiography

(Not used much anymore due to new generation CTPA scanning that is less invasive, less expensive, and uses less contrast)

39
Q

What kinds of PEs is CTPA a little less accurate at diagnosing?

A

Smaller, subsegmental PE

But who cares because they are irrelevant

40
Q

What would make someone ineligible to have CT-Pulmonary angiography (CTPA)

A

IV contrast allergy

Renal dysfunction

41
Q

What would be an abnormal VQ scan?

A

Mismatch between ventilation and perfusion

42
Q

Is VQ scanning sensitive? Is it specific?

A

It is sensitive, but not specific (many false positives)

43
Q

Who are the best candidates for VQ scanning

A

Patients who have a normal chest radiograph.

They have good ventilation already, so the poor perfusion would be obvious

44
Q

What are the classic findings on an EKG of someone with a PE?

A

S1Q3T3 pattern

Right ventricular strain

45
Q

Is chest x ray sensitive for PE? Is it specific?

A

Not sensitive. Not specific

46
Q

What are the CXR findings you would see on someon with a PE?

A

Hampton’s hump

Westermark sign

47
Q

What are the 8 PERC criteria to rule out a PE

A

Under 50 yo

HR under 100

95% pulse ox

No hempoptysis

No estrogen use

No prior DVT/PE

No leg swelling

No surgery/hospitalization in last month

48
Q

How many people who have PE will the PERC criteria miss?

A

1 in 50

49
Q

When is the PERC rule best used?

A

In patients who present with chest pain or dyspnea, in whom the gestalt estimate for PE is less than 15%

50
Q

How do you treat PE?

A

ANTICOAGULATION

Supplemental O2

Intubate

Vasopressors

51
Q

Which factor Xa inhibitor is subcutaneous?

A

Fondaparinux (Arixtra)

52
Q

Which factor Xa inhibitors are oral/

A

Rivaroxaban (Xarelto)

Apixaban (Eliquis)

Edoxaban (Savaysa)

53
Q

What is the oral direct thrombin inhibitor?

A

Dabigatran (Pradaxa)

54
Q

What kind of anticoagulant would you probably not use for someone with a PE who is stable?

A

IV unfractionated heparin

55
Q

When would you use IV unfractionated heparin?

A

Massive iliofemoral DVT

Hemodynamically unstable PE

Severe renal failure

Anyone who is more likely to require rapid reversal

56
Q

What is the anticoagulant of choice for people who are pregnant or who have active cancer?

A

LMW heparin

57
Q

What is the target INR range for someone on warfarin

A

2-3

58
Q

Why do you have to give another anticoagulant when you start warfarin?

A

Because warfarin takes 5 days to kick in

59
Q

What patients would you be nervous about giving anything but heparin and warfarin?

A

In patients who are bleeding risks and you wont be able to reverse the anticoagulant

  • prone to trauma
  • prone to falling (elderly/alcoholics)

Etc

60
Q

What is the reversal agent for unfractionated heparin?

A

Protamine

61
Q

What is the reversal agent for LMW heparin?

A

Protamine (typically incomplete reversal)

62
Q

What is the reversal agent for warfarin ?

A

Vitamin K

Fresh frozen plasma

63
Q

What is the reversal agent for Factor Xa inhibitors?

A

Andexanet alfa

$$$$$, hard to find

64
Q

What is the reversal agent for the direct thrombin inhibitor (Dabigatran/pradaxa)?

A

Idarucuzumab

$$$$$$$$

65
Q

What is another agent that can be used to help stop bleeding in everyone?

A

Activated prothrombin complex concentrate (aPCC)

66
Q

When should you test for inherited thrombotic disorders?

A

VTE before 45 yo
AND
a 1st degree relative with a VTE

67
Q

What should you test for if you decide to test your pt for inherited thrombotic disorders

A

Antithrombin deficiency

Protein S deficiciency

Protein C deficiency

Factor V Leiden

Prothrombin gene mutation

Antiphospholipid syndrome

68
Q

When would you consider an IVC filter?

A

Anticoagulation is contraindicated

Risk of bleeding outweighs risk of recurrent VTE

Recurrent PE despite anticoagulation

Hemodynamic/respirator compromise that is so severe, another PE might kill them

69
Q

What is the problem with IVC filters?

A

After they’ve had it for awhile, clots start to build up around and on top of the filter, which can then embolize to the lungs

It could also become dislodged and migrate

70
Q

Is there any evidence that anticoagulation PLUS an IVC filter is better than anticoagulation alone?

A

No

71
Q

Should your pt keep their IVC filter in forever?

A

No, remove it when no longer needed

72
Q

When is the only time you would use a thrombolytic for a PE?

A

If the patient has a massive PE, is unstable, has hypotension, and cardiogenic shock

AKA they’re gonna die

73
Q

How do you prevent clots in an admitted hospital patient who has no risk factors for DVT/PE?

A

Mechanical prophylaxis only (Intermittent pneumatic compression or TED hose)

74
Q

For admitted patients with one risk factor and no bleeding risk, how do we prevent clots?

A

Low dose SQ LMW heparin

No mechanical prophylaxis

75
Q

For admitted patients with multiple risk factors for VTE, how do we prevent clots?

A

Mechanical and pharmacological prophylaxis

BUT if they are a high bleeding risk, do mechanical only

76
Q

Should we admit patients who have DVT or PE?

A

Yes almost everyone should be admitted to at least start the anticoagulant therapy

Clin Med Exam 4 (Lauren) (5 decks)

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