VTE Flashcards
You already know about PE and DVT. What are some unusual locations for a VTE?
Unusual sites (portal vein, renal vein, cerebral venous sinus…)
Symptoms of DVT:
- Why does it cause leg pain?
Signs of DVT? - 3
What is meant by distal and proximal DVT?
DVT diverts the flow of blood to other veins
Increases pressure causing pain
Swelling
Tenderness
Reg leg
distal= popliteal and below proximal = above popliteal
Symptoms of PE:
Why does it cause SOB?
What are the 3 main symptoms?
Other symptom linked to the reason for SOB
Cardiac symptoms - 3
Systemic symptoms - 2
Due to hypoxia - tachypnoea compensates
Pleuritic chest pain
SOB
Haemoptysis
Cyanosis
Tachycardia
AF
Raised JVP
Dizziness/syncope/fall
Fever
Symptoms of PE:
Why does it cause pleural effusion?
Why does it cause pleural rub on auscultation?
They may have a weaker pulse on inspiration which is noticed on palpation of the radial pulse. What is this phenomenon called?
There is increased interstitial fluid in the lungs as a result of ischemia or the release of vasoactive cytokines.
They occur where the pleural layers are inflamed and have lost their lubrication.
Pulsus paradoxus
Risk factors:
DICE mneumonic
DVT/PE past medical history or thrombophilia
Immobility
Cancer - big risk factor for clotting
Estrogen - COCP/HRT
Risk factors:
Why may cause immobility?
Why does cancer increase the risk of clotting?
Which types of cancer are particularly associated? - O, P
Oestrogen - what increases oestrogen in the body? - 5
Why is it important to ask about pro-inflammatory conditions?
Recent surgery or travel (and trauma)
Activates thrombin - ovarian and prostate
Pregnancy Postpartum COCP HRT Obesity
They increase the likelihood of a VTE
What is the name of the criteria that is used to screen for PE’s and DVT’s?
Modified Wells Score
Wells Score:
Above what score is a PE likely?
What test should be done if the score is below this value?
What imaging should be done if the score is above this value, making a PE likely?
What could be started empirically until the diagnosis is confirmed?
> 4 (>2 for DVT)
D-dimer (not reliable in pregnancy)
CTPA
LMWH
Investigations:
Bloods and why - 4
Bedside:
- What would an ABG show for the PaO2 and PaCO2?
- Why does it cause resp alkalosis?
- Why is an ECG done? - 2
Resp alkalosis (due to hyperventilation + poor gas exchange)
U+E
FBC
Baseline clotting
D-dimers (Wells)
Low PaO2 and low PaCO2 (this is due to tachypnoea so more CO2 blown off)
Can see tachycardia
Right ventricular strain (Inverted T in V1 to V4)
Investigations:
Imaging:
CXR is usually normal.
- What may happen to vascular markings?
- What may you see as a result of increased interstitial fluid in the lungs as a result of ischemia or the release of vasoactive cytokines?
- What is the name of the shape you might see in the area of infarction?
====
What 2 scans can be used to confirm a PE?
Wedge-shaped area
Decreased vascular markings
Pleural effusion
CTPA
V/Q scan - good in pregnancy
What can make the D-dimer unreliable?
It rises with thrombosis, so:
- inflammation
- post-op
- infection
- malignancy
Management:
Why should you start Rx if there is a good story and signs, even if definitive investigations have not been done yet?
What 2 types of anticoagulants should be started immediately? - only one is used
What should be considered if they are haemodynamically unstable (SBP<90, ‘massive PE)?
Most deaths by PE occur within 1 hr
IV LMWH or fondaparinux
Thrombolysis (e.g. alteplase)
CHECK NICE GUIDELINES AS THEY’VE SAID ANTICOAGS (e.g. rivaroban)
Long-term Management:
How long should they be on anticoagulants?
Why would they need to be on it for the rest of their life?
How long should they be on anticoagulants if they have active cancer?
What should be investigated if patients have no known provoking risk factors?
3 months
Second VTE
6 months
Consider malignancy - CT CAP and mammography in women
Complications:
What is post-thrombotic syndrome?
What is chronic thromboembolic pulmonary HTN?
Post-Thrombotic Syndrome is when you have the ongoing symptoms of a blood clot, or deep vein thrombosis (DVT), in the leg. Some people who have had DVT or blood clots in the leg recover completely, but others still experience symptoms, and these symptoms are called PTS.
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare and progressive form of pulmonary hypertension (PH). CTEPH is caused by blood clots that don’t dissolve in the lungs. These clots cause scar-like tissue that clogs up or narrows the small blood vessels in the lungs.
Unprovoked clotting?:
Antiphosphilip syndrome is useful to know about:
- What is it first of all?
- Is it inherited or acquired?
- Why is it important to know about this?
Antiphospholipid syndrome (APS), sometimes known as Hughes syndrome, is a disorder of the immune system that causes an increased risk of blood clots.
Acquitted
Useful to know about because may need higher intensity anticoagulation or anti-platelet agents
