Chapter 153 - Compartment syndrome and venous gangrene

Question 1

Phlegmasia definition

Answer 1

Greek - phlegma = inflammation

Question 2

Cerulea definition

Answer 2

Latin - caeruleus = dark blue

Question 3

Dolens definition

Answer 3

Latin - dolens = hurting/suffering

Question 4

Alba definition

Answer 4

White

Question 5

Difference between Phlegmasia cerulea dolens and Phlegmasia alba dolens

Answer 5

PCD = IFDVT without adequate drainage
PAD = IFDVT with some drainage allowing venous return before derm and subdermal blood cause cyanosis

Question 6

Cause of cyanosis in PCD

Answer 6

Increase in deoxyhemoglobin in subdermal tissue

Question 7

Cause of gangrene in PCD

Answer 7

Small and microvessel thrombosis leading to tissue hypoperfusion

Question 8

Hemorrhagic bullae in PCD

Answer 8

poor prognosis
underlying tissue necrosis
associated with venous limb gangrene

Question 9

Treatment for PAD and PCD

Answer 9

1) therapeutic anticoagulation
2) wrap limbs from toes to inguinal crease
3) TPA or open thrombectomy within 24 hr

Question 10

Venous limb gangrene definition

Answer 10

soft tissue necrosis in a limb with DVT

Question 11

Phases of venous limb gangrene as per Tagariello

Answer 11

1) Phlegmasia alba dolens
2) phlegmasia cerulea dolens
3) venous limb gangrene

Question 12

Association of venous limb gangrene with other conditions

Answer 12

Almost all have either

1) cancer
2) serious conditions complicating proximal DVT

Question 13

Serious conditions that precipitate venous gangrene

Answer 13

1) warfarin necrosis
2) HIT
3) DIC
4) sepsis
5) purpura fulminans
6) pressor use
7) acute hepatic dysfunction

Question 14

Heparin induced thrombocytopenia epidemiology

Answer 14

2x in women than men

Question 15

Mortality of HIT

Answer 15

20-30%

Question 16

Types of HIT

Answer 16

Type I = innocuous benign 2 days after heparin occurs in 10-30%
Type II = antibody mediated disorder need to cut off heparin, warfarin and use others

Question 17

Mechanism of HIT

Answer 17

IgG bind heparin to PF4 –> prothrombotic state

Question 18

Timing of HITT

Answer 18

1) 5-10 days after UFH infusion

2) can be secondary response which is immediate

Question 19

Delayed onset HIT

Answer 19

HIT sera activating platelets in absence of heparin

heparin-independent activation of platelets

Question 20

Warfarin-induced skin necrosis targets

Answer 20

1) central skin

2) subcutaneous tissue over adipose tissue (breast, thigh)

Question 21

INR in warfarin-induced skin necrosis

Answer 21

supra-therapeutic

due to rapid depletion of Factor VII

Question 22

Thrombotic complication rate of HIT if untreated

Answer 22

50-89%

Question 23

White clot syndrome

Answer 23

Fibrin thrombus causing large vessel occlusion

Question 24

Half life of Protein C

Answer 24

9 hours

Question 25

Half life of Factor VII

Answer 25

5 hours

Question 26

Prothrombin half life

Answer 26

60 hours

Question 27

Treatment of warfarin induced skin necrosis in HIT

Answer 27

1) vitamin K

2) DOAC

Question 28

Cancer-associated DIC with venous limb gangrene key points

Answer 28

When patient with DVT gets a rise in platelet after heparin treatment, cancer DIC suspicious

Warfarin avoided

Question 29

Disseminated intravascular coagulation mechanism

Answer 29

1) platelet aggregation
2) pathologic thrombin generation
3) intravascular deposition of fibrin

4) endogenous fibrinolysis and protein C and S malfunction

Question 30

Diagnosis of DIC

Answer 30

1) underlying associated disease
2) prolonged thrombin time and partial thromboplastin time
3) plt < 100 or rapid fall
4) presence of fibrin/fibrinogen degradation product
5) low antiithrombin III

Question 31

Diseases associated with DIC

Answer 31

1) bacterial endotoxin
2) tissue injury
3) shock
4) metabolic acidosis
5) tumor-derived procoagulant microparticles

Question 32

Purpura fulminans define

Answer 32

Symmetric peripheral gangrene

1) no large vein thrombosis
2) skin and soft tissue necrosis

Question 33

Causes of purpural fulminans

Answer 33

1) septicemia
2) heart failure
3) metabolic acidosis
4) shock
5) pressor support

Question 34

Most common infectious cause of purpura fulminans

Answer 34

1) Neisseria meningitides 69% (children)

2) streptococcus 13% (elderly)

Question 35

Fasciotomy in venous obstruction and disease key points

Answer 35

No clear evidence
may improve healing may worsen
Thrombus removal most important
Can lead to chronic venous insufficiency due to disrupted calf pump