VTE

Question 1

What are the 3 components of Virchow’s triad? Does it predispose arterial or venous clots?

Answer 1

Endothelial dysfunction
Venous stasis / turbulent flow
Hypercoagulability
Venous

Question 2

A PE occurs when a thrombus embolizes and travels through the _____ side of the heart and becomes lodged in the _____, may cause right heart strain

Answer 2

A PE occurs when a thrombus embolizes and travels through the RIGHT side of the heart and becomes lodged in the PULMONARY ARTERIES, may cause right heart strain

Question 3

Compression stockings are used for patients that have a high VTE risk. What is the contraindication to their use?

Answer 3

Significant peripheral artery disease

Question 4

What drug is used prophylactically for patients at high VTE risk?

Answer 4

LMWH dalteparin

Question 5

What is the Well’s score?

Answer 5

Predicts the risk of a patient with symptoms actually having a DVT:?

Question 6

A DVT causes unilateral swelling and tenderness, dilated superficial veins, redness and oedema. What examination test can be done for a suspected DVT?

Answer 6

Measure calf distance 10cm down from tibial tuberosity, >3cm is significant

Question 7

What test is used for diagnosis of a DVT? What investigation is done alongside to aid diagnosis?

Answer 7

Doppler US for diagnosis

Measure D-dimers

Question 8

What is the sensitivity and specificity of d-dimers in DVT?

Answer 8

100% sensitivity
Low specificity
AKA everyone with a DVT will have high d-dimers but not everyone with high d-dimers will have a DVT
(also raised by pneumonia, malignancy, surgery, HF, pregnancy)

Question 9

What is the acute management of a DVT?

Answer 9

LMWH dalteparin BEFORE confirming diagnosis

Question 10

What is the long term management of a DVT? How long is treatment continued for?

Answer 10

Anticoagulation (warfarin or DOAC or LMWH)
For 3mth if obvious reversible cause
For 6mth if cause unclear or active cancer

Question 11

What is the 1st line management of a DVT in pregnancy?

Answer 11

LMWH dalteparin

Question 12

If a VTE is unprovoked and there is a FH of VTE, NICE recommends checking for what ?

Answer 12

Hereditary thrombophilia - commonest is factor V Leiden deficiency

Question 13

What surgical procedure can be done for patients with recurrent DVTs?

Answer 13

IVC filter

Question 14

If a patient presents with an unprovoked VTE, NICE predicts checking for APS antibody. It also recommends checking for cancer, what tests should be done?

Answer 14

Through history/exam
FBC, U+Es, LFTs,
Urinalysis
CXR
CT abdo pelvis if >40ry
Mammogram in women >40yr

Question 15

What is Budd-Chiari syndrome? What is the triad?

Answer 15

Hepatic vein thrombosis
Abdo pain + hepatomegaly + ascites
(Also causes acute hepatitis)

Question 16

Describe the chest pain in a PE

Answer 16

Pleuritic chest pain worse on inspiration

Question 17

Can a PE cause a low grade fever? Or a raised JVP? Or haemoptysis?

Answer 17

PE can cause a low grade fever, a cough with or without blood and a raised JVP

Question 18

Well’s score predicts the likeliness of a patient with PE symptoms actually having a PE. If the score is ABOVE what… what investigation should be done?

Answer 18

If Well’s score above 4 do CTPA

Question 19

Well’s score predicts the likeliness of a patient with PE symptoms actually having a PE. If the score is BELOW what… what investigation should be done?

Answer 19

If Well’s score below 4 do d-dimers

If normal rule out PE, if high do CTPA

Question 20

When investigating a PE, if a patient can’t tolerate contrast from a CTPA, what investigation can you do as an alternative?

Answer 20

V/Q scan

Question 21

What is the ECG appearance in a PE?

Answer 21

• Most normal or sinus tachycardia
• ST depression
• AF (new or revert)
• Right heart strain: ST depression in anterior leads, new RBBB)
• S1Q3T3 (deeper S waves in lead I, Q waves in lead III, inverted t waves in lead III)

Question 22

What is the initial management of a PE?

Answer 22

DOAC (apixaban, rivaroxaban), BEFORE confirming diagnosis

Plus oxygen, analgesia

Question 23

Name 3 DOACS

Answer 23

Apixaban, rivaroxaban, dabigatran

Question 24

How long should anticoagulation be continued in a PE?

Answer 24

3 month if obvious reversible cause

6 month if unclear cause / active cancer

Question 25

1st line long term management of a PE in pregnancy or cancer?

Answer 25

LMWH (not a DOAC)

Question 26

What are the indications for thrombolysis in a PE? What fibrinolytic drug is used?

Answer 26

If a massive PE with haemodynamic compromise

Streptokinase

Question 27

What is the commonest blood gas pattern seen in a PE and why?

Answer 27

Respiratory alkalosis
(Due to high RR blowing off CO2 causing low blood CO2 so alkalosis)
(Other main cause of respiratory alkalosis is hyperventilation; would have a normal pO2 but low pO2 in PE)