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A- Resp and cardio > VTE - DVT/PE > Flashcards

VTE - DVT/PE Flashcards

1
Q

Gold standard investigation for PE

A

CTPA

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2
Q

What are D-dimers a product of?

A

Clot breakdown
High levels indicate active coagulation

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3
Q

What hormone and linked meds increase the risk of DVT/PE?

A

HRT, COCP - oestrogen

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4
Q

What inherited clotting disorders can cause PE?

A

-Factor V Leiden
Antiphopsholipid syndrome

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5
Q

What route into the pulmonary blood supply do blood clots take?

A

Vena cava -> R side of heart -> pulmonary circulation

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6
Q

Risks of PE

A

Active malignancy, chemo
Pregnacy esp late, C section and
first 6 weeks postpartum (20 x higher risk)
Trauma - lower limb syndrome
DVT
Prev DVT/PE
Surgery last 2 months >30 mins GA esp ortho
Immobility >5 days

Less significant
Age >60
COCP/HRT
BMI>30
Significatn comorbidities - HD, metabolic, endocrine, neurological disability
Recent hospitalisation
Long distance sedentary travel >4 hours fligh
Varicose veins
Superficial vein thrombosis
Inherited clotting disorderrs eg factor V leiden, antiphospholipid
Other - Other factors, such as indwelling central vein catheter, nephrotic syndrome, chronic dialysis, myeloproliferative disorders, paroxysmal nocturnal haemoglobinuria, or Behçet’s disease.
>3 days immobility

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7
Q

How does a clot travel to the lungs

A

DVT -> R side of heart -> pulmonary artery

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8
Q

Specific questions to ask in a PE history

A

Travel
Pregnancy
Malignancy
COCP/HRT
Recent surgery/immobilisation

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9
Q

Investigations for PE

A

Bloods
ECG
ABG
ECHO if too unwell to get to a scanner - RV strain, hypokinesis
ABG - hypoxia, TI resp failure
CXR
CTPA = investigation of choice
VQ scan - pregnancy
Pulmonary angiograhy = gold standard

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10
Q

What investigation use to avoid radiation for PE in pregnancy?

A

V/Q scan - ventialtion perfusion scan

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11
Q

Bloods in PE why do and what find

A

Exclude other causes
Elevated D-dimer - highly sensitive, not specific
Troponin, BNP if strain on heart

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12
Q

ECG findings in PE

A

Normal
Sinus tachycardia most common
AF
non specific ST or T wave abnormalities
Right ventricular strain pattern V1 -V3
Right acis deviation
RBBB or S1Q3T3 pattern

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13
Q

When use VQ scan

A

Pregnancy
Also used if CXR normal, no significant symptomatic concurrent cardiopulmonary disease

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14
Q

Why often don’t use pulmonary angiography even though its the gold standard for PE diagnosis?

A

Invasive, significant complication rates compared with other investigations

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15
Q

Sources of emboli in PE

A

Most common DVT
Tumours
Fat - long bone fractures
Amniotic fluid pregnant women
Sepsis - tricuspid endocarditis, IVDUs
Foreign body
Air

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15
Q

Sources of emboli in PE

A

Most common DVT
Tumours
Fat - long bone fractures
Amniotic fluid pregnant women
Sepsis - tricuspid endocarditis, IVDUs
Foreign body
Air

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16
Q

Acute management of PE

A

Oxygen
Heparin - anticoagulate iwth SCLMWH or IV heparin infusion
Thrombolysis eg IV alteplase

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17
Q

When consider thrombolysis in PE

A

Critically ill or massive PE where there is circulatory failure - haemodynamic instability

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18
Q

What score predicts outcome PE/need for thrombolysis?

A

PESI - Pulmonary Embolism Severity INdex

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19
Q

What should be commnenced in first 24 hours after PE?

A

Warfarin or DOAC within 24 hrs

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20
Q

Examples of LMWH used for PE

A

Tinzaparin 175U/kg, enoxaprain 1.5U/kg

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21
Q

When is heparin continued/discontinued after PE?

A

DOAC - stop as soon as go on DOAC
Warfarin - continue for 5 days or until INR is in therapeutic range (2-3)

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22
Q

When should LMWH be used long term instead of warfarin or DOAC?

A

Active cancers

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23
Q

What does the lenght of PE treatment depend on?

A

Provoked, unprovoked or recurrent

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24
Q

How treat long term in provoked PE? eg precipitating factor

A

Warfarin or DOAC for 3 months, at 3 months weigh risk vs benefit in provoked

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25
Q

Symptoms PE

A

Dyspnoea
Chest pain - pleuritic, retrosternal
Cough and haemoptysis
Dizziness and syncope - RHF in severe cases

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26
Q

Signs of PE

A

Tachypnoea, Tachycardia
Hypoxia
Pyrexia
Elevated JVP
Gallop heart rhythm, widely split S2, tricuspid regurgitatnt murmur
Pleural rub
Systemic hypotnesion and cardiogenic shock in massive PE

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27
Q

How do you calculate risk for PE?

A

Wells score

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28
Q

Wells score components

A

Clinically suspected DVT = 3
Alternative diagnaosis less likely than PE = 3
Tachycardia >100 = 1.5
Immobilisation >3 days or surgery < 4 weeks ago = 1.5
Hisotry of PE or DVT = 1
Haemoptysis = 1
Malignancy = 1

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29
Q

When does a Wells score suggest PE is higher probability?

A

Over 4

30
Q

What to do if a Wells score is less than 4?

A

Low probability - do a d-dimer
If raised start LMWH -> CTPA/V/Q scan
If normal d-dimer seek alternative cause

31
Q

If Wells score over 4 what do?

A

Start LMWH + CTPA/V/Q scan

32
Q

What LMWH do you use in acute management of PE?

A

Tinzaparin 175U.kg or enoxiparin 1.5U/kg

33
Q

WHat do you see in a massive PE?

A

Systemic hypotnesion and cardiogenic shock

34
Q

What can untreated/resolved or acute severe PE cause

A

Chronic pulmonary hypertension

35
Q

Alternatives to WELLS score

A

GENEVA
PERC rule out criteria

36
Q

What is PERC criteria for

A

Rule out low risk patients

37
Q

What group of patients is YEARS algortihm used for to assess PE risk

A

Haemodynamically stable patietns over 18 and can be used in pregnancy

38
Q

How accurate are D dimers at predicting PE

A

Sensitive but not specific
Rule out test (screening)
Elevated in any pro-inflammatory state

39
Q

Why is VQ scan chosen over CTPA in pregnant women

A

Risk of maternal breast cancer due to radiation on lactating tissue in CTPA

40
Q

Negatives of VQ scan

A

Still radiation to foetus
Availability variable
Less sensitive in non pregnant patients
Unhelpful if abnormal CT or preexisitng lung disease

41
Q

Main function of CXR in PE

A

Rule out differentials - OFTEN CANT SEE on CXR

42
Q

When consider admission for PE

A

Haemodynamically unstable
CT/echocardiographic evidence right heart strain
Require supplemental oxygen
Comorbidities eg renal/liver faulure
Pregnant
High risk for bleeding

43
Q

Idiopathic/unprovoked PE treatment

A

Warfarin or DOAC for 6 months in unprovoked + rule out underlying cancer esp in older patients

44
Q

Recurrent PE vs active cancer and PE treatment

A

Recurrent - lifelong warfarin/DOAC
(active cancer - DOAC for 6 months)

45
Q

What is haemodynamic instability

A

-systolic BP <90
-sustained (>15 min) drop of >40mmHg
-Evidence of end organ hypoperfusion or cardiac arrest

46
Q

Pros and cons of thrombolysis

A

Reduces clot burden and improves mortality
Serious adverse effects eg life threatening bleeding possuble

47
Q

Treatment for patients evidence of R heart failure but no haemodynamic instability (submassive PE)

A

Intermediate risk
Usually dont offer thrombolysis
Careful monitoring in high dependemcy care in case of deterioration

48
Q

What does eGFR have to be to offer a DOAC

A

> 30

49
Q

What anticoagulation to offer if high risk of bleeding

A

Continious unfractionated heparin infusion - shortest halflife and most reversible agent

50
Q

What can acute PE that fails to clear cause

A

Chronic TE pulmonary hypertension

51
Q

What need to do long term if acute PE causing RH strain

A

Check ECHO at 6 months to ensure CTEPHypertesnion not occuring

52
Q

Unusual thrombosis sites

A

Portal vein
Renal vein
Cerbral venous sinus

53
Q

Distal vs proximal DVT

A

Distal - popliteal vein behind knww or bwlow
Proximal = above knee

54
Q

complications of PE

A

Post thrombotic syndrome
Pulm HOTN -> cor pulmonale
Psycholoical

55
Q

What would make a DVT unlikely

A

Negative D dimer and low wells score

56
Q

What is problem with DVT

A

Can be negative in PE in high risk froups
Can be postivie for other reasons - not specific

57
Q

Why treat in first 4 weeks vs maintencanceDVT

A

first 4 - prevent clot extension + mbolisation
After - prevent re clotting

58
Q

How long treat with unprovoked PE

A

Proximal DVT/PE - long term
Distal DVT - 3-6 months

59
Q

Contraindication DOAC

A

Impaired renal unction
Extreme weights
Elderly

60
Q

Which drug use if need INR 3-4

A

LMWH

61
Q

What anticoag drug increases risk of ICH

A

LMWH

62
Q

What anticoags are reversbile

A

Warfarin
Dabigatran

63
Q

What are thrombophilia screens useful for

A

Unprovoked VTE with suspicion of APS

64
Q

Three markers of APS

A

SLE anticoagulant
Ati-beta 2 glycoprotein IgG
Anticardolipin IgG

65
Q

What score is used for post thrombotic syndrome

A

Villalta

66
Q

What Villalta score means what

A

> 5 = diagnositic of PTS
15 or ulcers present = severe

67
Q

Symptoms of post thrombotic syndrome

A

Pain, cramps, heaviness, pruritis, paraesthesia
Oedema
Skin induration
Red, pain when compress
Venous ectasis

68
Q

When consider referral for PTS - managment

A

12 months after VTE for stenting of proximal deep veins
Mainly conservative management w pressure stockings in class I + II

69
Q

Presentation of CEPTH

A

Persisting hypoxia, SOB, chest pain

70
Q

Management of CTEPH

A

ECHO at 3 months - RV impair, raised RH pressures
Refer to pulm HPTN cinci

71
Q

What contraception is ok for women w prev VTE

A

All except oral oestrogen

72
Q

What atnicoag switch to when pregnant

A

LMWH

A- Resp and cardio (58 decks)

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