Case 7: Leg Swelling Flashcards Preview

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Flashcards in Case 7: Leg Swelling Deck (39):
1

What is the single greatest contributor to death in the United States?

SMOKING

2

Three leading causes of smoking attributable death

1. Lung cancer
2. Ischemic heart disease
3. COPD

3

Uncontrolled hypertension reduces life expectancy by

20 years

4

Four causes of hypertensive attributable death

1. Coronary artery disease
2. Hypertensive cardiomyopathy
3. Cerebrovascular disease
4. Chronic renal disease

5

Two causes of diabetic attributable death

- cardiovascular disease
- chronic renal failure

6

Risk of cardiovascular disease in diabetics is so high, it is assumed that

they have cardiovascular disease if they have diabetes

7

Second most common cause of death in United States

Obesity
- reduces life expectancy by 6-7 years

8

____% of PE are due to DVT

95%
PE carries high mortality (90% of deaths happen within first 2 hours) - so prevention and prompt Tx of DVT is key to reducing death as PE consequence

9

Half life of warfarin

40 hours

10

How long does it take for steady state of warfarin to be stable?

5 to 7 days

11

Foot exam for Diabetic patients

1. Sensory testing with 10 g monofilament + any one of following:
- vibration with 128 tuning fork
- illicit Achilles ankle reflexes
- pinprick sensation

2. Arterial supply assessment with DP/PT pulses + evaluate for skin changes: hair loss and temp changes

3. Inspect feet and footwear fit

12

Strongest risk factor in delayed ulcer healing and amputation

Peripheral vascular disease

13

Ulcer classification: Wagner Grading System

• Grade 1: Diabetic ulcer (superficial)
• Grade 2: Ulcer extension (involving ligament, tendon, joint capsule or fascia)
• Grade 3: Deep ulcer with abscess or osteomyelitis
• Grade 4: Gangrene forefoot (partial)
• Grade 5: Extensive gangrene of foot

14

Ulcer management: Grade 1-2

- outpatient: extensive debridement + local wound care + relief of pressure

If erythema + purulent exudate: treat for infection

15

Ulcer management: Grade 3

Evaluate for a) osteomyelitis and b) peripheral artery dz
- brief hospitalization

16

Ulcer management: Grade 4-5

Emergent hospitalization + surgery consult --> amputation

17

DDx for unilateral LE edema

- lymphedema
- cellulitis
- DVT
- venous insufficiency
- peripheral artery disease

18

Lymphedema

Painless or dull heavy sensation in leg
- early stage: pitting
- chronic stage: limb has woody texture, tissue becomes indurated and fibrotic

19

Cellulitis

Acute inflammatory infection of skin: erythema, swelling, heat (if small: strep, if large/ulcer/abscess: staph)
- RFs: diabetic nephropathy and PAD

20

DVT

Swelling, pain, discoloration of affected extremity + palpable cord of thrombosed vein, warmth
- can result in chronic venous insufficiency (valves become thickened or high pressures distend vein and separate leaflets)
- pain is worse when standing and relieved w elevation
- inflammatory response in leg - mild fever

Doppler ultrasound is best test

21

Venous insufficiency

Pitting edema + erythema + dermatitis + hyperpigmentation + skin ulceration near medial and lateral malleoli

22

Peripheral artery disease

Atherosclerosis in peripheral vessels
- claudication
- ABI < 0.9
- greatest modifiable risk factor: smoking

23

Most significant independent risk factors for DVT

- smoking
- obesity

24

Wells criteria for Dx of DVT
Each +1 (8)
One is -2 (other dx is more likely than DVT)

Positive criteria
1. active cancer
2. paralysis, paresis, recent plaster immobilization of leg
3. recently bedridden >3 days or major surg w/in 4 wks
4. local tenderness along distribution of venous system
5. entire leg swollen
6. affected leg is swollen >3 cm compared to Asx leg
7. pitting edema > in Sx leg
8. collateral superficial veins (non-varicose)

25

In order for DVT to be treated on outpatient basis:
3 patient reqs
2 home reqs

Patient reqs
- hemodynamically stable
- good kidney fxn
- low risk for bleeding

Home reqs
- stable and supportive
- daily access to INR monitoring

26

Heparin allows for

Immediate inhibition of growth of thromboemboli by allowing fibrinolytic dissolution to be achieved unopposed

27

Why is LMWH > unfractioned heparin

- longer biologic halflife (subQ once daily)
- no lab monitoring required
- thrombocytopenia is less likely
- dosing is fixed
*can be used in outpt setting

Unfractionated heparin requires hospitalization as it is administered IV with dosage based on weight and titrated based on activated PTT

28

LMWH can be substituted with

Fondaparinux (factor Xa inhibitor)

29

Thromboprophylaxis can be achieved with

a) Warfarin
b) Factor Xa inhibitor

30

Warfarin monitoring and titration

Titrate dose every 7 days to INR of 2-3

31

Factor Xa inhibitors

Do not require weekly lab monitoring of INR so adherence is easier, but more expensive and harder to reverse anticoagulation in face of bleed

32

First DVT or PE that is provoked by surgery or nonsurgical transient risk factor -- anticoagulate for?

3 months

33

First DVT/PE that is unprovoked but bleeding risk is high, anticoagulate for?

3 months

34

First DVT/PE that is unprovoked and bleeding risk is low/moderate, anticoagulate for?

Extended period of time

35

First DVT/PE that is unprovoked and due to active cancer, anticoagulate for?

Extended period of time

36

Patients with inherited coagulation disorders are anticoagulated

Indefinitely after episode of thrombotic disease

37

Workup patient for inherited thrombophilia if (4)

1. Initial thrombosis when <50 without immediately identified RF
2. Family Hx of VTE
3. Recurrent venous thrombosis
4. Thrombosis in unusual vascular beds: portal, hepatic, mesenteric, cerebral veins

38

If goal INR is substantially overshot...

1. Hold warfarin
2. Give ORAL dose of Vitamin K to reduce INR

If INR 5-9 - dc wafarin, give oral K, repeat INR in 24 hrs

39

How long to give LMWH, unfractioned heparin, or fondaparinux for as bridge to warfarin?

For at least five days + until INR is >2 for at least 24 hrs