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Pulmonary Block > Week 5 - VTE > Flashcards

Week 5 - VTE Flashcards

1
Q

When should you suspect DVT?

A

Any of the following criteria (2+ ==> high chance)

  • Unilateral leg swelling
  • Tibial swelling >3cm
  • Entire leg swollen
  • Cancer
  • Hx of DVT
  • Recent cast/immobilization/surgery
  • Superficial veins
  • Localized pain over venous area
  • No other likely Dx
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2
Q

How do you test for DVT if there is a low/moderate suspicion of DVT?

A

D-dimer

High sensitivity ==> Neg rules out DVT
==> Pos only suggests need for more testing

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3
Q

What are the imaging tests for DVT and when are they done?

A

Doppler US

  • accurate at assessing proximal veins
  • if Neg & low clinical suspicion ==> no DVT
  • if Neg & high clinical suspicion ==> retest next week
  • If Pos ==> DVT dx confirmed

Used in patients who have:

  • low/mod clinical probability & Pos D-dimer
  • high clinical probability
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4
Q

What is the presentation of PE?

A

Either SOB &/or Chest pain may be noticed

SOB

  • new onset
  • may only notice after exercising

Chest pain

  • pleuritic
  • pain on inspiration

may also have hemoptysis

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5
Q

When should you suspect PE?

A

Any of the following criteria and no other dx

  • Symptoms of DVT
  • HR > 100
  • Recent surgery/immobilization
  • Hx of DVT/PE
  • Hemoptysis
  • Malignancy
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6
Q

What are the imaging tests for PE and when are they done?

A

CT (gives more conclusive results) & V/Q scans

Used in patients who have:

  • low/mod clinical probability & Pos D-dimer
  • high clinical probability
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7
Q

What are some risk factors for VTE?

A

Surgery

  • ex. hip & knee replacements
  • immobility (casts, paralysis)

Hormonal Tx

  • pregnancy & 6 wks post-partum
  • HRT
  • OCP (oral contraceptive pills)

Cancer (active CA or currently in Chemo Tx)

Air travel

  • due to immobility
  • due to changes in air pressure
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8
Q

What are some hereditary risks of Thrombosis?

A

Factor V Leiden** (most common)
Prothrombin

More rare but more severe = Deficiency of:

  • Protein C
  • Protein S
  • Antithrombin

ONLY A/W VENOUS THROMBOSIS

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9
Q

List some non-hereditary risks of Thrombosis.

A

Anti-phospholipid syndrome

  • Lupus anti-coagulant
  • Anticardiolipin Ab
  • B2 Glycoprotein 1 Ab
  • *Must all stay persistently positive over 3 mo.

These people are at higher risk of recurrent thrombosis

A/W BOTH VENOUS & ARTERIAL THROMBOSIS

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10
Q

When would testing be ordered?

A

Not very often because it does not change tx/management and does not change outcome/risk of recurrence.
Only test if we think it would change tx/mgmt for a family.

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11
Q

Why do we treat pts with DVT/PE?

A

Reduce risk of:

  • death
  • post-thrombotic syndrome (clotting/swelling in leg)
  • pulm HTN due to thromboembolic disease
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12
Q

What is post-thrombotic syndrome?

What is the tx/prevention?

A
  • Chronic venous insufficiency
  • Chronic limb aching
  • Skin ulceration

Tx/Prevention:
Compression socks

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13
Q

What is the Tx for DVT/PE

A
  • *ANTI-COAGULATION**
  • block new clot formation
  • -> inhibit production of fibrin
  • don’t break down clot

Sometimes use:

  • Thrombolytics (Heparin- anti-inflammatory –> help relieve pain)
  • Surgical Thrombectomy
  • IVC filter
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14
Q

What types of anti-coagulants would be used to treat PE/DVT?

A

Start both tx immediately:

Immediate-acting:
- Heparin (UFH or LMWH)

Delayed-acting:
- Warfarin/Vit K antagonists

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15
Q

How long does Heparin need to be taken?

A

> 5 days, INR > 2 for 2 days

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16
Q

How long should Warfarin be taken

A

> = 3 months

17
Q

What is Rivaroxaban?

A 
Factor Xa inhibitor
Immediate-acting
Metabolized similarly between people
Don't need to monitor INR
~$3/d
18
Q

When would IV UFH be used?

A

Hopitalized/critically ill pts
Post-op, ICU
Risk of bleeding
Renal disease

*UFH has a short half-life and can be reversed with other agents

19
Q

Explain the pharmacokinetics of LMWH.

A 
SubQ
Longer half-life than UFH
Does not require monitoring
Much harder to reverse
Renally excreted ==> can accumulate in pt w renal failure
20
Q

Adverse effects of Heparin

A

Increased risk of bleeding &

Heparin-induced-thrombocytopenia (HIT)

21
Q

What is Heparin-induced-thrombocytopenia (HIT)

A

Drug-induced, immune mediated syndrome

  • Pt makes Ab against Heparin/PF-4 complex
  • can lead to thrombocytopenia or thrombosis
  • 5-7d after starting Heparin
  • Pts should receive CBC 5-7d after starting to monitor for this
22
Q

How would thrombocytopenia be diagnosed?

A

4 T Score:

  • Degree of Thrombocytopenia
  • Timing
  • Thrombosis
  • Alternative Cause

Can see lots of microthrombi in hand (dark extremities)

Determines low vs high risk

Low–> unlikely HIT
High–> do HIT assay and switch to new anticoagulant

23
Q

How would you treat HIT?

A

NOT WITH HEPARIN, EVER!

Alternate anti-coagulants:

  • Fondaparinux
  • Argatroban
  • Danaparoid
  • Lepirudin
24
Q

Tx of VTE?

A

Start Tx with anti-coagulation
Follow next day with dx US
If Pos, continue anti-coag tx

25
Q

What is Dabigatran?

A

Direct thrombin inhibitor
Given 2x/d
Side effects = GI (nausea)

26
Q

What is the most commonly used tx for venous thrombosis?

A

Rivaroxaban

27
Q

What is used to treat atrial fibrillation?

A

Rivaroxaban, Dabigatran, or Apixaban

28
Q

When should DVT prophylaxis be given?

A

For people not on long-term anti-coagulation, but have had previous thrombosis:

 - avoid hormonal tx
Prophylaxis:
 - Pregnancy & 6 wks post-partum
--> LMWH (Not Warfarin b/c a/w birth defects)
 - Post-op
 - Prolonged immobility

Pulmonary Block (12 decks)

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