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Flashcards in Session 15_DVT Deck (27)
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1

List several complications associated with bed rest:

• Decubitus ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin)
• Pneumonia
• DVT
• Constipation
• Urinary infection
• Osteoporosis
• Urostasis (stoppage of urination flow)

2

List several complications associated with surgery:

• Hypoxemia
• hypercapnea 
• anemia
• pain
• atelectasis (complete or partial collapse of a lung or a section (lobe) of a lung)
• pneumonia
• DVT
• PE
• Sepsis (a life-threatening complication of an infection)
•multi system failure

3

What does thrombosis refer to? When does it occur?

• Thrombosis refers to "a condition" of a blood clot
• Thrombosis occurs with slowing or disruption of blood flow
• It is most frequently occurs in the calf ("the formation or presence of a blood clot in a blood vessel. The vessel may be any vein or artery as, for example, in a deep vein thrombosis or a coronary (artery) thrombosis. The clot itself is termed a thrombus.")

4

What can DVT turn into when the clot breaks off and travels to the lung circulation?

a PE

5

a traveling thrombosis =

emboli

6

VTE =

venous thromboembolism

7

Where do DVT occur?

deep veins of the leg (eg. iliac, femoral, popliteal, tibial)

8

List potential causes of a DVT:

• long flights
• immobility due to anesthesia/ post surgical
• oral contraceptives
• paralysis 
•pressure to the calf 
• septicemia 
• cancer
• disorder of clotting
• atrial fibrillation or other heart failure
•damage to a blood vessel
• post trauma
• congestive heart failure
• genetics
• age
• smoking
• dehydration
• pregnancy

9

What veins are implied when talking about DVT?

• Peroneal vein in the calf
• Femoral vein of the thigh
• Axillary or subclavian vein of the arm
• pelvic veins

10

How do you prevent DVT?

~ Prophylaxis ~
• compression hose
•  SCDs (sequential compression device)
•  Preventative anticoagulation e.g. coumadin
•  mobilizing

11

Despite prophylaxis, 31% of patients undergoing total knee replacement develop DVT, and 27% of patients operated on for hip fracture develop DVt. What alternative method has been shown to reduce incidence to 16%?

low-molecular weigth heparin prophylaxis

12

How are DVTs diagnosed?

• Ultrasound of the blood vessels
• Wells DVT criteria
• Homans sign (?) - (senstivity and specificity not optimal)
--> dorsiflexion/ resistance test

13

Describe the procedure of Doppler ultrasonography:

• A blood pressure cuff is wrapped around the pt's ankle
• A transducer with gel on it is placed over the pulse points of the foot and lower leg. High-frequency sound waves bounce off the soft tissue, and the echoes are converted into images on a monitor.
•  This procedure is very accurate in detecting clots. Usually performed in a physicians' office or hospital outpatient diagnostic center.

14

Describe Well's criteria:

• Active caner? +1
• Bedrest >3 days or recent major surgery? +1
• Calf swelling >3cm compared to other leg? +1
• Entire leg swollen? Yes +1
• Calf tenderness along deep veins? +1
• Pitting edema, in the symptomatic leg? Yes +1
• Paralysis, paresis, or immobilization of the lower extremity? Yes +1
• Previous DVT? +1
• Alternative diagnosis to DVT likely? -2

15

How is Wells DVT criteria scored?

• High = >/- 3 points = DVT risk 75%
• Moderate = 1-2 points = DVT risk 17%
• Low =

16

Describe what D-Dimmer is and what a negative result implies:

• A blood test to help diagnosis DVT
• D-DIMER is a fibrin degradation product (FDP), a small protein fragment present in the blood after a blood clot is degraded
• Only present if the coagulation process has been activated
• A NEGATIVE result practically rules out thrombosis, a positive result can indicate thrombosis but does not rule out other potential causes
• Introduced in 1990

17

What are some signs and symptoms of DVT?

• Pain in the calf
•  Calf swelling
• redness
• Well's criteria
•  Positive Homans sign??

18

What are some complications of DVT?

PULMONARY EMBOLUS:
• Most PEs result from DVT
• 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
• Blockage to the pulmonary artery

19

Can you see a PE on a x-ray?

NO, can't see PE on x-ray

20

What are the signs and symptoms for when a DVT has become a PE (VTE)?

Symptoms = shortness of breath, cough, sharp/sudden chest pain
Signs = rapid pulse, hyotension, sweating, tachypnea, desaturation of the blood

21

Diagnosing PE; VQ (ventilation-perfusion) scan. Findings indicate what?

VQ scan finding = VQ mismatch in PE (high)

VQ mismatch in COPD, emphysema or atelectasis (low)

22

How do you prevent PE?

• Greenfield filter:
--> It is introduced through the jugular vein and is lodged in the inferior vena cava
--> Catches emboli

23

List some common pharmacological treatments of DVT/ pulmonary emoli:

• Anticoagulation such as: enoxaparin a.k.a. low molecular weight heparin (drug of choice since mid '90s)
• Standard unfractionated Heparin
• Coumadin aka. warfarin

(** note: while heparin does not break down clots that have already formed, it allows the body's natural clotlysis mechanisms to work normally to break down clots that have formed)

24

(After a DVT) when can a patient ambulate?

• When dose of anticoagulation is "theraputic"; usually within 6 hours
• Opinion varies by doctor
Recommendation from research: walk as soon and as much as possible with good compression therapy following anticoagulation therapy.
•  Ambulation also leads to better outcomes: decreased pain, swelling and concurrence/severity of postthrombotic syndrome

25

see slide 25 for algorithm on ambulation

see slide 25 for algorithm on ambultation

26

Research shows:

When compared to bed rest, early ambulation was not associated with a higher incidence of a new PE. Furthermore, early ambulation was assocated with:
• lower new PE and new or progression of DVT
• lower incidence of new PE and overall mortality

27

What are the 5 APTA recommendations?

1. Don't employ passive physical agents except when necessary to facilitate participation in an active treatment program
2. 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.
3. Don't recommend bed rest following diagnosis of acute deep vein thrombosis after the initiation of anticoagulation therapy unless significant medical concerns are present.
4. Don't use continuous passive motion machines for the postoperative management of patients following uncomplicated total knee replacement
5. Don't use whirlpool for wound management