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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
How treat long term in provoked PE? eg precipitating factor
Warfarin or DOAC for 3 months, at 3 months weigh risk vs benefit in provoked
25
Symptoms PE
Dyspnoea Chest pain - pleuritic, retrosternal Cough and haemoptysis Dizziness and syncope - RHF in severe cases
26
Signs of PE
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
27
How do you calculate risk for PE?
Wells score
28
Wells score components
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
29
When does a Wells score suggest PE is higher probability?
Over 4
30
What to do if a Wells score is less than 4?
Low probability - do a d-dimer If raised start LMWH -> CTPA/V/Q scan If normal d-dimer seek alternative cause
31
If Wells score over 4 what do?
Start LMWH + CTPA/V/Q scan
32
What LMWH do you use in acute management of PE?
Tinzaparin 175U.kg or enoxiparin 1.5U/kg
33
WHat do you see in a massive PE?
Systemic hypotnesion and cardiogenic shock
34
What can untreated/resolved or acute severe PE cause
Chronic pulmonary hypertension
35
Alternatives to WELLS score
GENEVA PERC rule out criteria
36
What is PERC criteria for
Rule out low risk patients
37
What group of patients is YEARS algortihm used for to assess PE risk
Haemodynamically stable patietns over 18 and can be used in pregnancy
38
How accurate are D dimers at predicting PE
Sensitive but not specific Rule out test (screening) Elevated in any pro-inflammatory state
39
Why is VQ scan chosen over CTPA in pregnant women
Risk of maternal breast cancer due to radiation on lactating tissue in CTPA
40
Negatives of VQ scan
Still radiation to foetus Availability variable Less sensitive in non pregnant patients Unhelpful if abnormal CT or preexisitng lung disease
41
Main function of CXR in PE
Rule out differentials - OFTEN CANT SEE on CXR
42
When consider admission for PE
Haemodynamically unstable CT/echocardiographic evidence right heart strain Require supplemental oxygen Comorbidities eg renal/liver faulure Pregnant High risk for bleeding
43
Idiopathic/unprovoked PE treatment
Warfarin or DOAC for 6 months in unprovoked + rule out underlying cancer esp in older patients
44
Recurrent PE vs active cancer and PE treatment
Recurrent - lifelong warfarin/DOAC (active cancer - DOAC for 6 months)
45
What is haemodynamic instability
-systolic BP <90 -sustained (>15 min) drop of >40mmHg -Evidence of end organ hypoperfusion or cardiac arrest
46
Pros and cons of thrombolysis
Reduces clot burden and improves mortality Serious adverse effects eg life threatening bleeding possuble
47
Treatment for patients evidence of R heart failure but no haemodynamic instability (submassive PE)
Intermediate risk Usually dont offer thrombolysis Careful monitoring in high dependemcy care in case of deterioration
48
What does eGFR have to be to offer a DOAC
>30
49
What anticoagulation to offer if high risk of bleeding
Continious unfractionated heparin infusion - shortest halflife and most reversible agent
50
What can acute PE that fails to clear cause
Chronic TE pulmonary hypertension
51
What need to do long term if acute PE causing RH strain
Check ECHO at 6 months to ensure CTEPHypertesnion not occuring
52
Unusual thrombosis sites
Portal vein Renal vein Cerbral venous sinus
53
Distal vs proximal DVT
Distal - popliteal vein behind knww or bwlow Proximal = above knee
54
complications of PE
Post thrombotic syndrome Pulm HOTN -> cor pulmonale Psycholoical
55
What would make a DVT unlikely
Negative D dimer and low wells score
56
What is problem with DVT
Can be negative in PE in high risk froups Can be postivie for other reasons - not specific
57
Why treat in first 4 weeks vs maintencanceDVT
first 4 - prevent clot extension + mbolisation After - prevent re clotting
58
How long treat with unprovoked PE
Proximal DVT/PE - long term Distal DVT - 3-6 months
59
Contraindication DOAC
Impaired renal unction Extreme weights Elderly
60
Which drug use if need INR 3-4
LMWH
61
What anticoag drug increases risk of ICH
LMWH
62
What anticoags are reversbile
Warfarin Dabigatran
63
What are thrombophilia screens useful for
Unprovoked VTE with suspicion of APS
64
Three markers of APS
SLE anticoagulant Ati-beta 2 glycoprotein IgG Anticardolipin IgG
65
What score is used for post thrombotic syndrome
Villalta
66
What Villalta score means what
>5 = diagnositic of PTS >15 or ulcers present = severe
67
Symptoms of post thrombotic syndrome
Pain, cramps, heaviness, pruritis, paraesthesia Oedema Skin induration Red, pain when compress Venous ectasis
68
When consider referral for PTS - managment
12 months after VTE for stenting of proximal deep veins Mainly conservative management w pressure stockings in class I + II
69
Presentation of CEPTH
Persisting hypoxia, SOB, chest pain
70
Management of CTEPH
ECHO at 3 months - RV impair, raised RH pressures Refer to pulm HPTN cinci
71
What contraception is ok for women w prev VTE
All except oral oestrogen
72
What atnicoag switch to when pregnant
LMWH

A- Resp and cardio (58 decks)

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