Venousthromboembolism

Question 1

A low risk patient with a negative D-Dimer has the same risk for PE as a low risk patient with ___________

Answer 1

PERC negative

Question 2

What percent of patients with DVT have PE?

What percent of patients with PE have DVT?

Answer 2

Pt’s with DVT: 40% have PE

Pt’s with PE: 70% have DVT

Question 3

Percent of patients with PE that have SOB?

Percent of patient with PE that have CP?

Answer 3

SOB: 80%

CP: 49%

Question 4

Symptom with the strongest association with PE?

Answer 4

Hemoptysis

however this is only present about 5% of the time

SOB is the most common complaint though

Question 5

Most common PEx/vital sign finding in PE?

Answer 5

Most common: Tachypnea

Tachycardia is only found in 24-30% of patients

Question 6

EKG findings of right heart strain suggestive of PE

Answer 6

S1Q3T3

New RBBB or incomplete RBBB

T-wave inversions in the anterior precordial leads and/or inferior leads. If NEW —> PE until proven otherwise.

Question 7

Of all the risk factors for PE, what are the strongest risk factors?

Answer 7

Surgery requiring general anesthesia within 4 weeks (also think major ortho surgeries like hips and knees)

Trauma within 4 weeks requiring hospitalization

Question 8

When can you use the age-adjusted D-dimer

how is it calculated?

Answer 8

> 50 year old

Age x 10 = new threshold for the d-dimer

Question 9

Define Massive PE

Answer 9

Persistent Hypotension: Systolic BP <90 for 15 minutes OR a baseline SBP decrease of >40 mmHg. Likely right heart strain too.

Question 10

Treatment of Massive PE

Answer 10

Pressors (epinephrine, norepi, dopamine) to treat hypotension - AVOID Fluids as this can worsen right HF.

HEPARIN (80 U/kg IV bolus, then 16-18 U/kg/hr infusion)

PLUS

IV Thrombolytics (Alteplase is FDA approved, Tenecteplase is not)

NOTE: if contraindications to thrombolysis then consider catheter-directed mechanical thrombectomy vs. surgical embolectomy.

Question 11

Define Submassive PE with Right Heart Strain

Answer 11

Normotensive or Intermittent Hypotension (remember that massive has SBP <90 for 15 min). With both radiographic AND biomarker findings of R heart strain.

Question 12

What are the radiographic findings of right heart strain?

Answer 12

CTA:

• RV > LV
• Reflux of contrast into the IVC or Liver

Ultrasound:

• Dilated or hypokinetic RV
• Estimated RV systolic pressure >40 mmHg

Question 13

Treatment of Submassive PE WITH right heart strain?

Answer 13

Controversial.

HEPARIN

+/- thrombolysis (look for patient with evidence of shock or hemodynamics compromise:

• shocks index > 1
• intermittent hypotension
• Lactate >2
• SaO2 <92% with distress)

Catheter-directed thrombolysis

Question 14

Treatment of Submassive PE WITHOUT right heart strain?

Answer 14

Consider outpatient management with oral anticoagulation by using:

• PESI score
• Hestia criteria

If low-risk —> outpatient management

If high risk —> admit either on oral anticoagulation or heparin

Question 15

Treatment of subsegmental PE?

Answer 15

Outpatient management. Use PESI and Heastia criteria to risk stratify

In some cases no anticoagulation may be preferred.

Question 16

These are signs of impending venous gangrene due to DVT.

What is the treatment?

Answer 16

Phlegmasia cereulan dolens AND Phlegmasia alba dolens

These are indications for catheter-directed thrombolysis