Prolonged immobilization - coach class syndrome - hospitalization Recent surgery or trauma - especially ortho Hx of cancer

Unilateral lower extremity - edema - erythema - warmth - ttp Decreased extremity pulses/cyanosis “Heavy legs” Palpable venous cord Homan’s sign

- Extremity pain - Venous dilation - Edema - Pigmentation - Skin changes - Venous ulcers

Lecture 8 - Hypercoagulable States Flashcards by john Thompson

3rd leading cause of death in hospital pts?

Pulmonary embolism

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Abbrox 40% of PE pts will develope?

proximal DVT

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Verchows triad

Vessel wall damage/trauma

Venous stasis

Hypercoagulabiity

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What causes venous stasis?

Immobility
Hyperviscosity (polycthemia_
Increased central venous pressures
- preggo/CHF

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While only 1% of the population ___ accounts for 50-60% of enous thromboembolism (VTE)

Inherited hypercoagulabilty

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Inherited hypercoagulabilty conditions?

Factor V leiden mutation
Antithrombin III deficiency
protein C deficiency
protein S deficiency
prothrombin gene mutation
antiphospholipid antibody syndrome (APS)

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What is included in antiphospholipid antibody syndrome (APS)?

Lupus anticoagulant
Anticardiolipin antibody
Anti-beta2-glucoprotein

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Acquired hypercoagulability conditions?

Advanced age
Immobilization
Inflammation
Pregnancy
Oral contraceptive use
Hormonal replacement therapy
Obesity
DM
Cancer

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Can VTE be idiopathic?

Yeah it can be

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VTE is rare right?

No its pretty common

1% incidence after age 60

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VTE includes?

DVT
PE
Post thrombotic syndrome

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Classic VTE hx?

Prolonged immobilization

coach class syndrome
hospitalization

Recent surgery or trauma
- especially ortho

Hx of cancer

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Cardiac symptoms that may be VTE?

Chest pain
Dypsnea
Limb ischemia
Stroke
Acute renal failure

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DVT and PE together?

70% Pts with PE have DVT

50% of pts with DVT have PE

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S/X of DVT

Unilateral lower extremity

edema
erythema
warmth
ttp

Decreased extremity pulses/cyanosis
“Heavy legs”
Palpable venous cord
Homan’s sign

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Bad signs with DVT?

Calf diameter >2cm difference

Cyanotic hue

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Homan’s sign?

Unreliable

Calf pain on foot dorsiflexaion

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Post-thrombotic syndrome (PTS) is a ?

Long term sequelae of DVT 2/2 chronic venous insufficiency

Approx 50% of pts 6mo post DVT

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What causes PTS?

Reflux due to valvular incompetence and venous hypertension due to thrombotic obstruction

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PTS S/S

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Extremity pain
Venous dilation
Edema
Pigmentation
Skin changes
Venous ulcers

Acute PE S/S?

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sudden SOB
pleuritic chest pain
tachypnea
hemoptysis
syncope

ECG changes

MC ECG findings for PE?

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Sinus tach

Nonspecific ST and T wave changes

S1-Q3-T3 usually means?

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Massive acute PE

Cor pulmonale

S1-Q3-T3

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Look at slide 25 if your forgot

Wells criteria?

Score given for PE probabilty Slide 26

Well’s criteria - VTE risk scores?

= 4 - PE unlikely get a d-dimer D-dimer <500 (low) ruled out VTE > 4 - PE likely - get a imaging study

If you have a wels criteria VTE risk of >4 you should not?

Order a d-dimer - doesnt change anything

HX warning signs for VTE?

Virchow’s triad risk factors - hx of immobilization - surgery - obesity - fam hx - lower extremity trauma - malignancy - OCPs or HRT - pregnant - stroke

VTE PE?

Pay special attention to the vascular system Chest Heart Abdominal organs and skin

VTE labs?

``` CBC Coag studies (PT/PTT) ECG Renal function ABGs (resp alkalosis) Hypercoagulable workup d-dimer ```

Imaging for DVT?

Compression venous US

Imaging for PE?

CXR - r/o other shit CT pulmonary angiography ventilation-perfusion lung scan - ( if ct not available)

Tx for VTE?

Anticoagulation - LMW Heparin - unfractionalte IV heparin BRIDGE with WARFARIN

How to bridge warfarin for VTE?

Heparin + oral warfarin/coumadin x 5 days until INR of 2 or more has been achieved x 24hrs

Alternates to heparin tx?

Factor Xa inhibitors — no warfarin bridge - Rivaroxaban - Apixaban

Risks and benefits of factor Xa inhibitors?

Risks: bleeding and is irreversible (maybe not anymore) - cannot monitor compliance (must trust pt) Benefits: NO INR monitoring or daily inj

1st episode and reversible (provoked) VTE therapy?

3 months of LMWH

Cancer VTE tx?

LMWH x 3-6 months Then LMWH indefinitely until cancer free Coumadin is not effective in neoplasm induced VTE

1st episode idiopathic (unprovoked ) VTE tx?

3 months therapy But Case-by-case, they may need lifelong Get a hypercoagulability evaluation

Recurrent VTE and irreversible risk factors therapy?

Life long tx

What is the pulmonary embolism severity index (PESI)

Assesses the 30 day mortality outcomes to triage into: - outpatient - inpatient - ICU level Slide 37

PESI score risk categories

< 65 : outpatient 66-85 : consider outpatient 86-105 : consider inpatient 106-125 : inpatient management >125 : ICU management

Malgnancy and VTE?

Malignancy increases risk of VTE VTE may be initial presentation of malignancy

Warning signs for Malignancy?

Unprovoked VTE Recurrent VTE wile on anticoagulants Multi-site VTE Recurrent unprovoked superficial thrombosis

Low, moderate, and high suspicion for malignancy testing?

Low: no further testing Moderate: CT of abdomen and pelivs High: routine chem, CBC, CT, mammography, gynecology consult, PSA

Pretty much all cancer pts should be?

On LMWH At least for first 3-6 months but prob longer

Who to screen for inherited thrombophilia?

- Family hx of unprovoked VTE - unprovoked VTE <45 y/o - recurrent VTE - recurrent pregnancy loss

Thrombophilia testing post anticoagulant

You should check at least 2 wks post completion of initial oral anticoagulant - it can alter the results

Donating blood

Is a great excuse to eat the way i do every other day

Lecture 8 - Hypercoagulable States Flashcards

(49 cards)