VTE

Question 1

Inpatient VTE prophylaxis: what is it important to know/ ask about?

Answer 1

Any current bleeding/ bleeding risk

Weight + renal function (reduced dose if <50kg)

Question 2

Clinical features of PE

Answer 2

Dyspnoea, tachypboea, pleuritic chest pain

May also have features of DVT

Question 3

Less common features of PE

Answer 3

Retrosternal chest pain (due to RV ischaemia)

Cough + haemoptysis

Question 4

Signs of PE:
HR
O2 sats
temperature
JVP
Sound
BP

Answer 4

TachyC
Hypoxia
Pyrexia
Raised JVP
Pleural rub
Hypotension

Question 5

What is a massive PE?

Answer 5

Involves both pulmonary arteries OR results in haemodynamic compromise

Question 6

What is a provoked PE?

Risk of recurrence

Answer 6

Associated with a transient RF

RFs can be removed = reduced risk of recurrence

Question 7

What is an unprovoked PE?

Risk of recurrence

Answer 7

No identifiable RFs

Inc risk of recurrence

Question 8

Pathophysiology of PE

Effect on pulmonary artery

Answer 8

Lung tissue is ventilated but not perfused = intrapulmonary dead space + impaired gas exchange

increased pulmonary artery pressure

Question 9

Most common cause of PE

Answer 9

DVT

Question 10

Other causes of PE (think sources)

Answer 10

Tumours 
Fat 
Amniotic fluid
Sepsis
Foreign body
Air

Question 11

Tumours most likely to cause PE

Answer 11

Prostate + breast

Question 12

Most common cause of a fat PE

Answer 12

long bone fractures

Question 13

Most common cause of an air PE

Answer 13

Surgery

Question 14

6 major risk factors for PE

Answer 14

DVT (70%)
Active cancer
Recent surgery (last 2 months)
Immobility 
Lower limb trauma/ fracture
Pregnancy + 6 weeks pp

Question 15

What % of PEs have no identifiable RFs?

Answer 15

30-50%

Question 16

How much does having an active cancer increase the risk of VTE?

Answer 16

4 fold risk

Question 17

Other RFs for VTE

Answer 17

Age >60
COCP
Obesity
Long-haul travel/ thrombotic disorders/ varicose veins

Question 18

Can you see PE on a CXR?

Answer 18

No

Question 19

ECG changes in PE

Answer 19

Tachycardia

ST + T wave abnormalities

Question 20

Two-level PE wells score (5 components)

Answer 20

Clinical features of DVT
HR >100
Immobilisation >3 days or surgery in last 4 weeks
Haemoptysis
Cancer (in last 6 months)

Question 21

Next step if PE wells score >4
What does this mean?
What if there is a delay?

Answer 21

PE likely!!

CTPA

If there is a delay, give immediate LMWH or fondaparinux

Question 22

Give 2 examples of LMWHs

Answer 22

Tinzaparin

Enoxaparin

Question 23

If PE wells score is <4
Next step
What does this mean?

Answer 23

PE unlikely

Arrange a D dimer

Question 24

Next stages after D dimer
Positive
Negative

Answer 24

Pos: CTPA

Neg: consider alternative diagnosis

Question 25

What is a D dimer?

Answer 25

Protein fragments released when a blood clot breaks down

Question 26

D dimer has a negative predictive value - what does this mean?

Answer 26

Normal D dimer = PE is unlikely BUT lots of other factors can cause a high D dimer (i.e. low PPV)

Question 27

Other factors causing a high D dimer

Answer 27

Pregnancy, cancer, inflammation

Question 28

Mx of PE

Answer 28

ANTICOAGULATE!! | LMWH/ fondaparinux/ oral anticoagulant

Question 29

Mechanical interviention if recurrent PE likley

Answer 29

IVC filter

Question 30

When is thrombolysis indicated

Answer 30

THROMBOLYSIS = FIRST LINE FOR MASSIVE PE

Question 31

Example of thrombolysis How is it given? Dose

Answer 31

50mg bolus of ALTEPLASE, followed by IV infusion

Question 32

When should thrombolysis be delivered?

Answer 32

Within 4.5 hours of onset

Question 33

Contraindications for thrombolysis (6)

Answer 33

``` PMH of intracranial haemorrhage Brain tumour Stroke in last 3 months Suspected dissection Recent surgery Recent head trauma ```

Question 34

What is a long-term complication of DVT?

Answer 34

Post-thromboticc syndrome (lifelong pain + swelling of the leg)

Question 35

Presentation of DVT

Answer 35

Swollen, red, painful, tender leg Dilated superficial veins N.B. small/ partially-occluding thrombus may be asymptomatic

Question 36

Wells sore for DVT (7)

Answer 36

``` Active cancer in last 6 months Recent immobilization Localised tenderness Entire leg is swollen Calf swollen >3cm more than other leg Pitting oedema Collateral superficial veins Previous DVT ```

Question 37

Wells score results

Answer 37

2+ DVT likely | 1 point or less = DVT unlikely

Question 38

Next stage if DVT likely after wells score | What if this can't be arranged within the time frame?

Answer 38

Proximal leg vein USS within 4 hours If can't be carried out, do a D Dimer + give 24 hr dose of parenteral anticoagulant

Question 39

Next stage if DVT unlikely after wells score

Answer 39

D-dimer

Question 40

D-dimer: Positive Negative

Answer 40

Positive: USS within 4 hours Negative: consider alternative diagnosis

Question 41

Initial management of DVT

Answer 41

LMWH + arrange outpatient follow-up

Question 42

Duration of treatment following a DVT

Answer 42

3 months

Question 43

DDx: superficial thrombophlebitis

Answer 43

Painful, tender area of skin Firm superficial vein + overlying erythema (N.B. may co-exist with DVT)