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52 Cards in this Set

  • Front
  • Back
What percentage of DVTs are asymptomatic?
50 - 60%
What are causes of venous stasis?
• CHF, MI, stroke • Immobilizations • Obesity • Pregnancy • Varicose veins
What is the treatment of a pregnant women with DVT?
• Heparin is the drug of choice • can use Warfarin in 2nd or 3rd trimester only
What are some causes of vessel injury?
• fractures • major surgery (CABG, heart surgery) • previous DVT • trauma • venous catherization
What are some hypercoagulable states?
• malignancy • estrogen use • pregnancy • clotting factor abnormalities
Give examples of clotting factor abnormalities
• Protein C & S deficiency • Antithrombin III deficiency • Activated Protein C • Prothrombin mutations
What are major risk factors of a venous thromboembolism (VTE)?
• cancer • major trauma • prior VTE • surgery of the lower extremities • venous stasis
What are signs and symptoms of a DVT?
• pain, tenderness, cyanosis • swelling / edema • warmth • redness / erythema
What are diagnostic tests used to evaluate for DVT?
• Ultrasound venous doppler (noninvasive, most widely used) • Contrast venography (invasive, used in non-conclusive ultrasound)
What percentage of pulmonary emboli originate from a DVT?
What are signs and symptoms of PE?
• cyanosis • hemoptysis rarely present (indicates hemorrhage or pulmonary infarction) • hypotension • low grade fever • neck vein distention • rapid onset of dyspnea ot tachypnea with some chest pain • tachycardia • unexplained syncope
What are basic test used to diagnose a PE?
• arterial blood gas (ABG) • chest x-ray • EKG
What are objective tests used to diagnose a PE?
• V/Q scan (most common) • echo • MRI • pulmonary angiography • spiral CT
Name 2 thrombolytics used in the treatment of a DVT or PE
• Alteplase • Streptokinase
True/False: Thrombolytics are the drug of choice for treating a DVT or PE
Thrombolytics are not the drug of choice because of all the adverse effects (such as increased bleeding). The correct answer is: False
What are anticoagulants that can be used to treat a DVT/PE?
• Heparin • LMWH • Warfarin
What is the mechanism of action for Heparin, LMWH, and Warfarin?
• Heparin: immediately inhibits activity of thrombin • LMWH: immediately inhibits activity of factor Xa • Warfarin: inhibits synthesis of vitamin K dependent coagulation proteins
True/False: Warfarin should be started at the same time as Heparin or LMWH
Warfarin (Coumadin) should be started at the same time because it will take 2-3 days to become therapeutic The correct answer is: True
What are baseline labs to get for a patient suspected of having a DVT / PE?
PT, PTT, CBC, Platelets, D-Dimer * also check for contraindications
What are imaging studies that should be done for a patient with a suspected DVT / PE?
V/Q scan, Echo, Doppler
What is the dosing of Heparin with a confirmed patient with a DVT / PE?
• weight based (use actual body weight) • 70 Units/kg bolus and then 15 units/kg/hr • adjust according to PTT
What is the dosing of Enoxaparin (Lovenox) with a patient confirmed for having a DVT / PE?
• 1 mg/kg sc q12 hrs • if CrCl < 30 ml/min, then q24 hrs
What is the effect of Argatroban on the INR?
• Argatroban can falsely elevate the INR • INR goal for a patient on Argatroban will be between 5-6
What is the dosing of Warfarin?
• start on day 1 at 5 mg • adjust according to INR (goal 2-3) • treat for about 3 months
What lab is used to monitor Warfarin (Coumadin)?
When do you stop the heparin or LMWH when you're overlapping with Warfarin?
stop after 4-5 days of combined treatment and therapeutic for at least 3 days
What are some of the difference between Heparin & LMWH?
• Heparin is absorbed faster through IV than Lovenox sub-q • Lovenox is cleared slower and has a longer half-life • Heparin is cheaper • Heparin has less protein binding » shorter half-life • Heparin is easier to monitor (by monitoring PTT) • Lovenox monitor is more difficult & expensive (have to monitor anti-Xa levels)
Name the LMWH that are available
• Dalteparin (Fragmin) • Enoxaparin (Lovenox) • Tinzaparin (Innohep)
Why does LMWH have less monitoring?
because you don't dose adjust according to PTT
What are labs that can be monitored on patients on LMWH?
• Hgb, Hct, PLT, PTT
True/False: LMWH has a reduced incidence of heparin-induced thrombocytopenia
The correct answer is: True
What are adverse effects of heparin and LMWH?
What are patients that must be on DVT prophylaxis?
• abdominal / pelvic surgery • hip fracture / replacement • immobilzation • knee replacement • major trauma
What is the dosing of Lovenox for DVT/PE prophylaxis?
• Lovenox 40 mg sc Q24hrs • if CrCl < 30 ml/min, Lovenox 30 mg sc Q24hrs
What is the dosing of Heparin for DVT/PE prophylaxis?
• Heparin 5000 IU sc Q8hrs (or 12hrs) *no renal adjustment needed
What are factors that should be considered when administer DVT/PE prophylaxis?
• risk of recurrent venous thromboembolism (VTE) • risks for major bleeding • patient compliance • patient preference
What is the recommended length of DVT/PE prophylaxis for a patient with one episode of venous thromboembolism?
• from a 2° cause » 3 months • idiopathic » 6 months • from cancer or protein C or S deficiency » 6 months
What is the recommended length of DVT/PE prophylaxis for a patient who has had two episodes of VTEs?
indefinite prophylaxis treatment or filter placement
What are risk factors for bleeding complications?
• age > 65 • aspirin use • history of GI bleed • recent surgery • renal failure • stroke • thrombocytopenia
What is the most common location of bleeding complications?
GI tract and urinary tract
What is the treatment of a patient with life-threatening bleeding that is on heparin?
• stop heparin and revese effect with protamine sulfate • 1 mg of protamine neutralizes about 100 units of heparin
Why must protamine be infused slowly?
protamine can induced hypotension
What do you do if the patient is on Warfarin and the INR is above the therapeutic range?
discontinue warfarin
What do you do if the patient is on Warfarin with a high INR and non-life threatening bleeding?
Vitamin K 5-10 mg PO
What do you do if the patient is on Warfarin with a high INR and life-threatening bleeding?
• Vitamin K 5-10 mg SC (1 time) • +/- plasma
Why should you not give Vitamin K if a patient is on Warfarin but not bleeding?
will reverse anticoagulation and will have to restart anticoagulation from the beginning (will require hospitalization)
Why should you never give Vitamin K IV?
can cause severe hypotension
What are complications of anticoagulants?
• Heparin Induced Thrombocytopenia • Skin Necrosis • Hypersensitivity • Bleeding
What are drugs that can be used to treatment HIT?
use direct-thrombin inhibitors: • Argatroban • Angiomax (Bivalirudin)
What are drugs that increase PT?
• androgens (progesterone, testosterone, oral contraceptives, steroids) • thyroid hormones (synthroid, levothyroxine)
What are drugs that decrease PT?
• barbituates • estrogens • carbamezapine • griseolfulvin • phenytoin • rifampin
What are alternative/herbal drugs that can be used for anticoagulation?
• Fish Oils • Garlic • Ginko Biloba • OTC products (aspirin, NSAIDS, Pepto-Bismol, alcohol, alka-seltzer) • Vitamin E