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CR2 > Venous Thrombosis And Pulmonary Embolism > Flashcards

Venous Thrombosis And Pulmonary Embolism Flashcards

1
Q

Thrombosis

A

Pathological clot formation within a blood vessel

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2
Q

Embolism

A

Part of a clot breaks off and travels through circulation until obstructed by vessels of smaller diameter

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3
Q

What colour are venous thrombi

A

Red

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4
Q

What colour are arterial thrombi

A

White - platelets and fibrin, few RBCs

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5
Q

Are venous or arterial thrombi more common

A

Venous

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6
Q

Deep vein thrombosis

A

Thrombus formed in deep vein

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7
Q

Where does a distal deep vein thrombosis form

A

Calf veins

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8
Q

Where does a proximal deep vein thrombosis form

A

Popliteal vein or above

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9
Q

What I’d the most common DVP site

A

Popliteal vein

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10
Q

Pulmonary embolism

A

Dislodged thrombus migrating to pulmonary vasculature

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11
Q

Embolus

A

Dislodged thrombus

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12
Q

How does leg muscle contraction aid venous return from legs

A

Muscle contraction squeezes vein opening proximal valve and pushing blood to heart

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13
Q

What happens if leg muscles don’t contract for a prolonged period

A

Valves remain closed and blood between them becomes stagnant, causing clotting above and below valved

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14
Q

What can dislodge a clot after a period of extended immobility

A

Muscle contraction

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15
Q

What is the most common route a clot may take to the brain

A

Through patent foramen ovale

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16
Q

Why do emboli often get stuck in pulmonary arteries

A

Arteries get smaller as they branch, before this arteries as getting bigger as the clot moves centrally

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17
Q

Saddle embolism

A

Large pulmonary embolus gets stuck in bifurcation of pulmonary trunk

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18
Q

Factors in Virchow’s triad

A

Endothelial injury
Stasis or turbulence of blood flow
Blood hypercoagulability

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19
Q

How does flowing blood prevent platelet adhesion to wall and clotting

A

Stimulates endothelium to release anticoagulants inc NO and prostacyclin

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20
Q

Risk factors for decr blood flow in deep veins

A

Immobilisation
Long haul flights
Obesity
Sickle cell disease

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21
Q

What does heparin sulphate and what does it do

A

Sulphide containing polysaccharide on luminal surface of endothelial cells
Form feathery projections into blood vessel lumen to prevent platelet adhesion

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22
Q

What can cause vessel wall damage

A

Chronic inflammatory disease
Smoking
Obesity
Diabetes

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23
Q

How can chronic inflammatory disease increase clot formation

A

Damage endothelial wall and decr amount of attached heparin

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24
Q

What can cause hypercoagulability

A

Antithrombin III deficiency
Protein C deficiency/resistance
Protein S deficiency/resistance

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25
Q

What is the most common DVT/PE risk in younger people

A

Factor V Leiden mutation - causes resistance to activated protein C

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26
Q

Thromboembolism risk factors

A

Pregnancy
Prolonged immobilisation
Previous VTE
Contraceptive pill
Long haul travel
Cancer
Heart failure
Obesity
Surgery
HRT
Thrombophilia
Severe burns
Age

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27
Q

How does pregnancy increase thromboembolism risk

A

Coagulant factor production increases in liver

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28
Q

DVT signs and symptoms

A

Pain
Erythema
Tenderness
Warmth
Superficial venous dilation
May be asymptomatic

29
Q

DVT differential diagnoses

A

Musculo-tendinois injury
Superficial thrombophlebitis
Cellulitis
Compression of iliac veins
Congestive cardiac failure
Lymphoedema
Lymphangitis

30
Q

What is used to estimate probability of DVT and PE in a patient

A

Wells’ scores

31
Q

What are the 2 risk categories for DVT and PE

A

Likely - wells score 2+
Unlikely - wells score 1 or less

32
Q

DVT clinical features - Wells score

A

Active cancer
Paralysis, paresis, or recent plaster immobilisation of lower extremities
Recently bedridden for 3+ days or major surgery within 12wks needing anaesthesia
Localised tenderness along distribution of the deep venous system
Entire leg swollen
Calf swelling 3cm larger than asymptomatic side
Pitting oedema confirmed to symptomatic leg
Collateral superficial veins
Previously undocumented DVT

33
Q

When is a proximal leg vein ultrasound scan offered to a patient

A

Wells score 2 points or more

34
Q

What test should be done if a proximal leg vein ultrasound scan is negative in a patient with a wells score over 2

A

D dimer test

35
Q

D dimer

A

Fibrin degradation product

36
Q

When is d dimer released into the blood

A

Thrombus degraded by fibrinolysis
Inflammation
Cancer
Pregnancy

37
Q

Pulmonary embolism symptoms

A

Dyspnea
Pleuritic chest pain
Cough
Sub sternal chest pain
Haemoptysis
Fever (but <39*c)
Syncope
Unilateral leg pain
Chest wall tenderness

38
Q

When is pleuritic pain worst

A

Inspiration

39
Q

Haemoptysis

A

Coughing up blood

40
Q

Syncope

A

Fainting

41
Q

Pulmonary embolism signs

A

Tachypnoea
Rales
Decreasing breath sounds
Accentuated second heart sound
Tachycardia
Fever
Diaphoresis
SIgns and symptoms suggesting thrombophlebitis
Lower extremity oedema
Cardiac murmur
Central cyanosis

42
Q

Why is pulmonary embolism difficult to diagnose

A

Patients may have mild or no signs and symptoms

43
Q

Pulmonary embolism differential diagnoses

A

Pneumothorax
Pneumonia
Myocardial infarction
Pericarditis
Pleurisy
Musculo skeletal chest pain

44
Q

Pulmonary embolism investigations

A

Blood gases
Chest x ray - exclude other diagnoses
ECG - rule out CVD

45
Q

Classic PE ECG

A

deep S wave lead I
Q wave lead iii
Inverted t wave lead iii

46
Q

What 2 level PE wells score suggests PE is likely

A

More than 4 points

47
Q

What 2 level PE wells score suggests PE is unlikely

A

4 or less points

48
Q

PE clinical features on 2 level wells score

A

Clinical signs and symptoms of DVT
Alternative diagnosis less likely than PE
heart rate >100 bpm
Immobilisation more than 3 days or surgery in prev 4wks
Previous DVT/PE
Haemoptysis
Malignancy

49
Q

PE imaging

A

Pulmonary angiography
Ventilation perfusion lung scintigraphy
CT pulmonary angiography

50
Q

PE causes of death

A

Acute right ventricular overload
Respiratory failure
Pulmonary infarction

51
Q

PE treatment

A

Immediate subcutaneous low molecular weight heparin
Oral anticoagulant

52
Q

How does heparin prevent clot formation

A

Binds to and Activates antithrombin -> activated complex inactivates factor Xa -> prevents conversion of prothrombin to thrombin

53
Q

How does heparin decrease PE mortality

A

Stops thrombus propagation in pulmonary arteries
Stops thrombus propagation at emboli source
Reduces frequency of further pulmonary embolism

54
Q

Heparin complications

A

Increased risk of bleeding
Heparin induced thrombocytopenia

55
Q

High risk PE patients

A

Haemodynamic support
Respiratory support
Exogenous fibrinolytics
Percutaneous catheter directed thrombectomy
Surgical pulmonary embolectomy

56
Q

How long are patients put on oral anticoagulants for PE

A

Identifiable temporary risk factor - 3 months
Active cancer - 6 months
No identifiable risk factor - indefinitely

57
Q

Why are direct oral anti coagulants DOACs increasingly being prescribed instead of warfarin

A

Lower risk of bleeding

58
Q

How does warfarin reduce plasma levels of factors II, VII, IX, and x

A

Vitamin K+ antagonist

59
Q

Why must treatment be started with heparin instead of just giving warfarin

A

Warfarin has a delayed onset of actiom

60
Q

Why can warfarin not be given in pregnancy

A

Tetarogenic
Can cause material bleeding

61
Q

Why must warfarin dose be changed if patient put on antibiotics

A

Antibiotics kill vitamin k producing bacteria in gut, leading to decr coagulation and bleeding

62
Q

Dabigatran

A

Orally active direct thrombin inhibitor

63
Q

Rivaroxaban and apixaban

A

Orally active factor Xa inhibitors

64
Q

What are rivaroxaban and apixaban used to treat

A

DVT
PE
reduce risk of recurrent DVT and PE
Prophylaxis of DVT
Prevent blood clots in atrial fibrillation

65
Q

When can rivaroxaban and apixaban not be used

A

Significant liver disease
End stage kidney disease

66
Q

How can venous thromboembolism be treated during pregnancy

A

Low molecular weight heparin

67
Q

How can venous thromboembolism be treated while breastfeeding

A

Low molecular weight heparin
Warfarin

68
Q

How are patients with active cancer and associated thrombosis treated

A

Low molecular weight heparin more effective than warfarin
DOACs
Treatment reviewed after 3-6 mo

69
Q

How are patients who can’t take anti coagulants treated for venous thromboembolism

A

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CR2 (33 decks)

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