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Flashcards in DVT and PE Deck (53):
1

which vessels can have a thrombosis?

any vessel

2

venous thronboembolism
-includes
-common complication in...
-occurs most frequently in...

includes deep venous thrombosis and pulmonary embolism
common complication in the ICU
occurs most frequently in the calf

3

which veins are we worried about finding blood clots (VTE) in

pelvic veins
axillary or subclavian vein of the arm
femoral vein of the thigh
peroneal vein in the calf

4

potential causes of a DCT

long flights
immobility due to anesthesia/post surgical
septicemia
cancer
disorder of clotting
atrial fib or other HF

5

DVT S/S

pain in the calf
calf swelling
redness
Well's criteria
positive Homan's Sign

6

Dx of DVT

ultrasound of the blood vessels
-doppler ultrasonography
very accurate
usually performed in a physician's office or hospital outpatient diagnostic center

7

D-dimer test
-what is D-dimer
-only present if
-negative result means
-positive result means

D-dimer is a fibrin degradation product
only present if coagulation process has been activated
negative result practically rules out thrombosis; positive result can indicate thrombosis but does rule out other potential causes

8

when is a FDP present

present in blood after a blood clot is degraded

9

D-dimer
-specificity and sensitivity
-what happens if patient has a high pre-test probability
-if low pre-test but high D-dimer, what happens

high sensitivity
poor specificity
if patient has high pre-test probability of developing a VTE
-anticoagulant therapy is initiated, regardless of D-dimer results
if low and positive test, further testing (duplex US) is warranted

10

Homan's Sign
-describe

pain occurs at the back of the knee or calf
ankle is slowly and gently dorsiflexed
sensitivity and specificity not optimal

11

what are the Well's Criteria?

active cancer: +1
bedrest >3 days or recent major surgery: +1
calf swelling >3cm compared to other leg: +1
entire leg swollen: +1
calf tenderness along deep veins: +1
pitting edema in the symptomatic leg: +1
paralysis, paresis, or immobilization of the LE: +1
previous DVT: +1
alternative diagnosis to DVT likely: -2

12

Wells DVT criteria
-what is required to be put into each strata
-DVT risk for each strata

high
->/= 3 points
-DVT risk: 75%
moderate
-1-2 points
-DVT risk: 17%
low
-0 points
-DVT risk 3%

13

DVT potential complications

pulmonary embolus

14

pulmonary embolus
-what is an embolus?
-what happens with a PE

if a blood clot were to "embolize," this means it has borken loose and traveled through the circulatory system where it blocks another blood vessel
piece of the thrombus breaks off, travels through the R side of the heart and into the pulmonary artery
can lodge in one of the smaller pulmonary capillaries

15

PEs
-most develop from...
-can you see them on X-ray

most result from DVT
can't see a PE on X-ray

16

PE
-what is it

clot that moves into your lungs and blocks the blood supply

17

PE
-symptoms
-signs

symptoms
-SOB
-cough
-harp chest pain - sudden
signs
-hypotension
-fainting
-tachypnea
-desaturation of blood
-rapid pulse

18

PE
-why is it dangerous

blocks an artery
-prevents the exchange of oxygen into the bloodstream
-causes a decrease of oxygen delivered to the organs and body systems

19

death rates of patients with PE who recieved
-mechanical ventilation
-cardiopulmonary resuscitation
-thrombolytic treatment

ventilation
-80%
CPR
-77%
thrombolytic
-30%

20

patients with PE who are stable enough for diagnostic procedures
-what tests
-mortality rates

spiral CTs and V/Q-scans
mortality rates of 1-2%

21

VQ scan
-what is it
-used for...

nuclear medicine imaging study
VQ scans can be used to help diagnose pulmonary embolism in patients who cannot receive iodinated contrast (X-ray dye), such as that used in computed tomographic angiography (CTA)

22

VQ scan
-how is ventilation determined

radioactive chemical is inhaled to evaluate which parts of the lung receive oxygen

23

VQ scan
-when and how is perfusion determined

performed after a radioactive chemical is injected into an IV to map the blood flow to the lungs
then compared to the ventilation part

24

prevention of PE method

Greenfield filter

25

Greenfield filter
-how is it introduced
-function

introduced through the jugular vein and is lodged in the inferior vena cava
catches emboli

26

pharmacological Tx of DVT/PE

anticoagulants
-Enoxaparin aka low molecular weight heparin (LMWH) is Tx of choice since mid-90s
-standard unfractionated Heparin
-Coumadin a.k.a. Warfarin

27

what interferes with Coumadin function

garlic
St. John's Wort
cranberry juice
ginsent
aspirin
NSAIDs

28

standard unfractionated Heparin
-function

does not break down clots that have already formed
allows the body's natural clot lysis mechanisms to work normally to break down clots that have formed

29

pharmacological prevention

use of LMWH prophylactically reduces incidence to 16%
anticoagulants are the most frequently used form of VTE prophylaxis in the at-risk population
LMWH was the most commonly prescribed anticoagulant
mortality in untreated PE is approximately 30%, but with adequate (anticoagulant) treatment, this can be reduced to 2-8%

30

what is the most common preventable cause of in-hospital death

blood clots

31

prophylactic prevention of DVT

compression hose
sequential compression device (SCD)
preventative anticoagulation e.g. coumadin
mobilizing
pulmonary embolism accounts for 5-10% of deaths in hospitalized patients, making VTE the most common preventable cause of in-hospital death

32

what is used more for VTE prevention?
-pharmaceutical or mechanical

pharmaceutical

33

are mechanical prophylaxis used more in surgical or medical patients

surgical

34

rate of DVTs in TKA and hip fracture patients

31% of TKAs
27% of hip fracture patients

35

how many people worldwide receive VTE prophylaxis?

40% medical
58% surgical

36

how effective is VTE prophylaxis in surgical patients
-Cochrane review (pharma + mechanical vs. just pharma)

75% reduction when using pharma and mechanical in conjunction

37

VTE is often preventable with...

judicious use of preventative measures in the form of thromboprophylaxis and mechanical antiembolism stockings

38

omission of thromboprophylaxis within the first _____ of ICU admission without obvious reasons is associated with a higher risk of mortality in the ICU

24 hours

39

mechanical prevention effectiveness

mechanical methods reduced risk of proximal venous thrombosis by 50% and pulmonary embolism by 40%
in absence of clear contraindications, patients undergoing a surgical procedure would be expected to derive net benefit from mechanical compression

40

when anticoag is contra'd, what can be used to do mechanical thromboprophylaxis (as it is indicated)

graduated compression stockings (GCS)
intermittent pneumatic compression (IPC)

41

thromboprophylaxis by mechanical means alone is recommended for...

critical care patients at high risk of bleeding with contraindications to prophylaxis with anticoagulant agents

42

when is anticoag not an option
-when should pharmacologic Tx be started into this situation

for acutely ill hospitalized medical patients at increased risk of thrombosis who are bleeding or at high risk for major bleeding
when bleeding risk decreases, and if VTE risk persists, begin pharmacologic thromboprophylaxis

43

when can mobility be used as prevention?

when dose of anticoagulation is "therapeutic;" usually within 6 hours
walk as soon and as much as possible with good compression therapy following anticoagulation therapy

44

outcomes of mobility as prevention

leads to better outcomes
-decreased pain
-decreased swelling
-decreased occurrence/severity of post-thrombotic syndrome

45

for long-distance travelers at increased risk of VTE (previous VTE, recent surgery or trauma, active malignancy, etc.), what are the recommendations

frequent calf muscle exercise, or sitting in an aisle seat if feasible

46

for general and abdominal-pelvic surgery patients at very low risk for VTE, what does the research recommend

not specific pharmacologic or mechanical prophylaxis be used other than early ambulation

47

in patients with acute DVT of the leg, what is suggested

early ambulation over initial bed rest

48

in patients with acute DVT of the leg and severe pain and edema, what do you do
-ambulation
-other therapy

ambulation may need to be deferred
reasearch suggests use of compression therapy in these patients

49

early ambulation of acute DVT patients with anticoagulation compared to bed rest

not associated with a higher incidence of new PE, progression of DVT, and DVT related deaths
for patients who sufferend moderate or severe pain initially, a better outcome can be seen in early ambulation group, regarding to the remission of acute pain in the affected limb

50

early ambulation was associated with a trend towards...

a lower incidence of new PE and new or progression of DVT than bed rest
-trend towards lower incidence of new PE and overall mortality

51

take-home message

know the clinical guidelines

52

take-home message
-what are the general clinical guidelines

patients presenting with DVT who are able to ambulate do not need to be kept at bed rest
best rest has no influence on the risk of developing PE among patients with acute DVT of the lower limbs
bed rest has a lack of influence even it patients presenting with acute submassive PE

53

APTA's 5 recommendations (not necessarily for VTE

don't employ passive physical agnets except when necessary to facilitate participation in an active treatment program
don't prescribe underdosed strength training programs for older adults
-instead, match the frequency, intensity, and duration of exercise to the individual's abilities and goals
don't recommend bed rest following Dx of acute DVT after the initiation of anticoagulation therapy unless significant medical concerns are present
don't use continuous passive motion machines for the postoperative management of patients following uncomplicated total knee replacement
don't use whirlpool for wound management