Venous Disease + Pulmonary Embolism Flashcards
(70 cards)
1
Q
What is a venous thrombus
A
Fibrin and red cells
Develops in areas of stagnant blood causing back pressure
2
Q
What is an arterial thrombus
A
Fibrin and platelets
Causes ischaemia and infarction
3
Q
What causes a venous thrombus
A
Stasis
Hypercoagulable
Vessel damage
4
Q
What makes VTE unlikely
A
If on anti-coagulation
5
Q
What are the symptoms of a DVT
A
Leg swelling - measure diff in calf circumference as well as swelling Calf tenderness Pitting oedema Warmth Erythema Prominent veins Mild pyrexia Tachycardia
6
Q
What is differential of DVT
A
Gout
Popliteal cyst
Arthiritis
7
Q
What are the RF for DVT split into general, underlying, drug
What is high risk surgery
A
Age Obesity Immobility e.g. bed rest / long haul flight Trauma Post op - pelvic / orthopaedic Pregnancy - up to 6 weeks post partum Varicose veins PMH FH
Underlying
- Malignancy - pelvic
- HF
- Nephrotic
- Heritale thrombophilia- Factor V leiden / anti-phosphoplipid
- Polycythaemia
- Sickle cell
Drug
- HRT
- OCP
- Tamoxifen
- Anti-psychotic
8
Q
How do you investigate suspected DVT
A
Well's score If low risk = D-dimer If D-dimer -ve can exclude DVT If high risk or +ve D-dimer = doppler USS If USS +Ve = treat as DVT If USS -ve = can exclude DVT
9
Q
What does Wells look at
A
Paralysis / immobilisation >3 days Active cancer Surgery >12 weeks Tenderness Enitre leg swollen Calf >3cm asymptomatic Pitting oedema Collateral superficial veins Previous DVT Another Dx more likely = -2
10
Q
How do you treat DVT and how do you monitor
A
SC LMWH for 5 days or until INR 2-3 Unfractioned heparin - used in renal failure Give if delay in USS / Dx APTT to monitor Anti-coagulation for 3 months - Warfarin - DOAC - Or through cancer / pregnancy If clot idiopathic / low risk of bleeding continue for longer
11
Q
How do you prevent DVT
What is preferred in orthopaedic surgery
A
TED stockings
Early mobilisation
Daily LMWH injections to all immobile patients
Fondaparinux (factor Xa inhibitor) decrease risk of DVT over LMWH in major ortho surgery
Stop OCP / HRT before surgery (4 weeks)
12
Q
When ae graduated compression stockings indicated
A
Chronic venous insufficiency Varicose Oedema Post-phlebetic Not to treat DVT
13
Q
What is post phlebitis / thrombotic syndrome and how do you manage
A
Chronic venous insufficiency after DVT due to hypertension Swelling Discomfort Heavy calf Itch Pigmentation Varicose vein Ulceration Manage with compression stockings
14
Q
What is a D-dimer and what else is it raised in
A
Breakdown product
Sensitie marker of thrombus but not specific
Also raised in malignancy / HF / renal / infarction / sickle / surgery / trauma so not reliable
e.g. PE common after hip fracture but D-dimer will be raised post-trauma / surgery
15
Q
What causes PE
A
DVT - usually in proximal femoral or iliac 50% idiopathic and 50% underlying cause Rarely RV thrombus post MI Septic emboli R side IE Fat / air / amniotic fluid
16
Q
What are the symptoms
A
Pleuritic chest pain Sudden onset SOB + no chest signs = think PE Cough Haemoptysis Hypoxia Dizzy / syncope Tachycardia Tachypnoea Pleural rub Crackles Fever
17
Q
What are signs of massive PE
A
Severe SOB and tahcy Pleural effusion Dullness on percussion Collapse due to drop in CO Cyanosis Low BP Raised JVP Altered heart sounds - 4th HS Cardiac arrest
18
Q
How do you Dx PE
A
FBC, U+E, clotting
CXR to exclude other cause (enlarged artery / decreased vascular) - always order first
ECG
ABG - alkalosis due to hyperventilation (pH normal due to anaerobic respiration buffering) but low O2 (hyperventilation due to anxiety = high O2)
Calculate Geneva
19
Q
What does Geneva score look at
A
S+S DVT Other Dx unlikely Tacycardia Surgery Previous Active cancer Haemoptysis
20
Q
If moderate or high risk what happens
A
CTPA or V/Q scan
No place for D-dimer
21
Q
When would you do V/Q
A
Pregnancy
Renal failure
Allergy to contrast
22
Q
What do you do if low risk
A
D-dimer
If high = CTPA
23
Q
How do you treat VTE
A
Oxygen if hypoxic
Thrombolysis = 1st line if circulatory failure e.g. hypotension
DOAC = 1st line for 3 months
If low risk of bleed can continue for longer or if malignancy
Shorter if on anti-platelet / bleeding risk
LMWH if delay in Dx or if using warfarin as takes a few days till INR 2-3
LMWH for 6 months if proven malignancy
24
Q
What should INR be
A
2-3
25
What do you do for idiopathic clot
```
Stay on for longer as higher risk of another as prone
Hx and exam
CXR
FBC, Ca, LFT, urine dip
Do all of these
```
Consider
CT CAP / mammogram etc
Haematology for thrombophilia screen
26
What do you do for massive PE
Thrombolyse = 1st line
| Vena cava filter if recurrent / active bleeding
27
What are complications
Pulmonary haemorrhage / infarction = pleural rub and pleuritic pain
Hypertension
RHF
28
What are ECG changes
Sinus tachy
RH strain - RBBB, V1+V2, T wave inversion
S1,Q3, T3
Deep S, pathological Q and inverted T
29
When are DOAC CI
When is LMWH CI
Pregnant
Breast fed
Malignancy
LMWH CI if already on warfarin / DOAC / active bleeding
30
Why are you SOB in PE
V/Q mismatch
| Shunt created
31
What is varicose veins and what causes varicose veins
Dilated torturous superficial veins
Valves to prevent back flow = damaged
Proximal obstruction or weakness damages valves
Blood flows back from deep veins into superficial veins which become dilated and engorged leading to more damage and increased pressure
DUE TO INCREASED PRESSURE
Occurs at sapheno-famoral and sapheno-popliteal junction
32
What are the symptoms and complications
```
Discomfort
Burning
Nocturnal cramps
Swelling
Tightness
Discolouration
Haemorrhage as fragile skin over veins
Superficial thrombophlebitis
Pruritus
Spider veins - no Rx
Haemosiderin, lipodermatosclerosis, venous eczema
Venous ulcers
Non-pitting oedema
```
Increased risk of infection, ulcers, and DVT
33
What are RF / 2 causes
2 obstruction - DVT / pregnancy / pelvic tumour
AV malformation
Congenital valve absence = rare
```
RF = increase pressure
Standing
Twins
Multiple pregnancy
Pelvic tumour
Prengnacy
Previous DVT
OCP
Trauma
FH
```
34
How do you investigate
Duplex USS to look for site
Check deep venous system competent before removal - if DVT = incompetent
+Ve Trendelenburg
ABPI to exclude PAD
35
How do you treat
Conservative
- Lose weight
- Education e.g. avoid standing
- Graduated compression stockings
- Skin care
Surgery
Endovenous = 1st line (cannulate vein pass catheter and heat + laser to fibrose)
USS guided sclerotherapy = 2nd line
Open Surgery - strip vein under Ga = 3rd line
Compression stockings if pregnant
36
When is open surgery CI
```
DVT as need deep venous to compensate
Pregnancy
Comorbid
Arterial insuffiency
Obesity
```
37
When is intervention indicated
```
Superficial thrombophlebitis
Symptomatic varicose veins
Chronic venous insuffieincy
Superficial vein thrombosis
Leg ulcer
Bleeding
Anxiety
Cosmesis
```
38
What are complications of surgery
```
Haemorrhage
Thrombophlebitis
Wound
Saphenous nerve damage
DVT
```
39
What does chronic venous insufficiency affect
Deep veins
40
What causes chronic venous insufficiency
Venous hypertension creates back pressure
Due to failure of muscle pump
or Obstruction
41
What causes failure of muscle pump
```
Venous reflux
Obstruction - DVT
Neuromuscular
Obesity
Inactive
```
42
Superficial vein
Varicose
43
Deep vein
DVT
44
What are symptoms of chronic venous insufficiency
Ankle oedema as veins leaky and blood leaks out
Telangtasia
Venous eczema as skin becomes dry and inflamed
Hemosiderin pigmentation - brown (HB breaks down and deposited)
Hyperpigmentation
Lipodermatosclerosis as skin becomes tight and fibrotic
Venous ulceration >4 weeks
Warm
45
How do you Dx chronic venous insufficiency
History and examination
ABPI - calculate as if arterial compression would damage
Duplex to check flow of vein = 1st line
46
How do you treat
```
Elevate
Manual drainage
Compression stockings or bandage
Naproxen = 1st line for superficial thrombophlebitis
Dressing
Eczema creams
Physio/ OT
Exclude DVT
```
47
What do you not give in chronic venous insufficiency
Diuretic
48
What causes lymph oedema
```
Inadequate drainage of lymphatic system
Congenital - presents in first 3 decades
Malignancy
Surgery - after LN clearance
RT
Infection
Post DVT
```
49
How do you treat
```
Prone to infection / ulcers / venous failure
Massage
Elevation
Manual drainage
Compression
```
50
What causes venous ulcers
Hypertension 2 to chronic venous insufficiency
51
What are the symptoms
```
Painless
Large and irregular
Other features of insufficiency
Above ankle
Affect gaiter region
Shallow ulceration
```
52
How do you Dx
Duplex USS
ABPI to exclude arterial
Biopsy if non-healing to exclude malignancy / Marlins ulcer
53
How do you Rx
```
Refer to venous ulcer clinic
Managed by district nurses
Good wound care - debride, clean, dress
Manage RF
Best rest and elevation
Compression after excluding PAD
Tissue viability nurse
Plastic surgery
Refer if >12 weeks or >10cm for skin graft
```
54
Arterial ulcers
```
Toes and heels
Painful
Gangrene
Cold
No pulse
Pain at night when legs elevated
Tend to be smaller with more regular border
Low ABPI
```
55
Neuropathic ulcers
Plantar surface of metatarsal and hallux
Due to pressure
Shoes to prevent
56
Pyoderma gangrenosum and what is Rx
IBD / RA
Erythematous nodules or pustules which ulcerate
Rx = steroid
57
Marjolin's ulcer
SCC at site of chronic inflammation e.g. OM / burns after 10-20 years
Mainly lower limb
58
Vein anatomy
```
IVC
Common iliac
Internal iliac
External iliac
Femoral
Popliteal
Arterial and posterior tibial
Long saphenous (superficial) -> femoral (arise dorsal venous arch and travel anterior to medial malleolus)
Short saphenous -> popliteal (arise plantar venous arch and posterior to lateral malleolus)
```
59
What nerve close to superficial veins
Sural
60
Do superficial veins have muscle pump
No only deep veins
| Deep veins are within muscle so can withstand higher pressure
61
What are the 3 tests to Dx chronic venous insufficiency
Tap test
Hand held doppler
Trendelenburg
62
What is the tap test
One hand on saphenofemoral junction
One on long saphenous above knee
Tap junction
If transmits =.incompetence
63
What is the hand held doppler
Put your hand over junction
Squeeze calf
Single whoosh if competent
Double if reflux back
64
What is the trendelenburg test
Drain superficial by lying flat and raising legs
Apply pressure over junction
Stand up
If don't dilate = vein competent
If dilate even with pressure = incompetent
65
What are veins that you can remove without affecting patient
Renal as collateral adrenal and gonadal tae over
IVC
Facial - transected in carotid endarectomy
66
How could a DVT cause systemic ischaemia
If DVT passes into heart and patient has a VSD allowing blood clot to move into L side of heart and into systemic circulation
COMMON EXAM
67
What should everyone in hospital get
VTE risk assessment
68
If increased risk what do they get
LMWH
Caution in renal failure
If CI i.e. due to risk of bleed = compression stockings
69
When does great saphenous join deep system (femoral vein)
3cm below and lateral to pubic tubercle
70
Where does small saphenous join deep (popliteal)
Popliteal fossa
