Dvt And Pe

Front 1

Risk factors for PE from PIPOED II Study

Back 1

Surgery within the last 3 months
Travel 4 hours in the past month
Prior pulmonary embolism
Immobilization
Trauma to lower extremity and pelvis during the past 3 months
Current or past history of thrombophilias
Malignancy
Stroke
Paresis
Paralysis
Heart failure
Chronic obstructive pulmonary disease (COPD)
Smoking
Central venous instrumentation within the past 3 months

Front 2

Vichows Triad

Back 2

Front 3

Inherited Risk Factors for PE

Back 3

Factor V Leiden mutation
Antiphospholipid antibody syndrome
Antithrombin III deficiency
Protein C deficiency
Protein S deficiency
Prothrombin gene mutation
Increased factor VIII activity
Activated protein C (APC) resistance
Dysfibrinogenemia
Hyperhomocysteinemia

Front 4

Deep Venous System of Lower Extremity

Back 4

Calf (distal DVT)

-Anterior tibial

-Posterior tibial

-Peroneal

Thigh (proximal DVT)

- Polpiteal vein

- Superificial/deep femoral vein

- External Illiac Vein

Front 5

Superficial venous system of lower extremity

Back 5

Greater/Lesser saphenous veins

Perforating veins

Front 6

Differential Diagnosis of DVT

Back 6

Muscle strain, hematoma
Popliteal (Baker’s) cyst
Lymphedema
Cellulitis
Vasculitis
Fracture
Superficial thrombophlebitis
Chronic venous insufficiency
Proximal venous compression (e.g., tumor, gravid uterus)
Congestive heart failure (swelling usually bilateral)
Hypoalbuminemia (swelling usually bilateral)

Front 7

Wells Score for DVT

Back 7

- Active cancer (treatment ongoing or within previous 6 months or palliative)
- Paralysis, paresis, or recent plaster immobilisation of the lower extremities
- Recently bedridden for more than 3 days or major surgery, within 4 weeks
- Localised tenderness along the distribution of the deep venous system
- Entire leg swollen
- Calf swelling by more than 3 cm when compared with the asymptomatic leg
(measured 10 cm below tibial tuberosity)
- Pitting oedema (greater in the symptomatic leg)
- Collateral superficial veins (non-varicose) 1
- Alternative diagnosis as likely or greater than that of deep-vein thrombosis (SUBTRACT 2)

Front 8

Mnemonic for Wells DVT Rule

Back 8

C3POR2D2

C3

Cancer

Collateral superficial veins

Calf Swelling

3PO

Pitting oedema

Odema of whole lege

Previous DVT

+

Tenderness along deep venous sytem

R2

Recent immoblization/surgery

Recent paralysis/paresis/plaster

D2

Diagnosis other than DVT as/more likely

Front 9

Risk categories and probability of DVT in validation study

Back 9

Low (-2 to 0) = 3%

Moderate (1 to 2) = 17%

High (3 or more) = 75%

Front 10

DVT WORK-UP ALGORITHIM INCORPORATING WELLS SCORE

Back 10

Front 11

Long term Anti-coagulation

Back 11

- 3 months OAC for identified transient risk factor

- 6 months OAC for 1st idiopathic/selected thrombophilia

- Long term LMWH for Cancer associated

- Recurrent at least 6 months (asses with thrombo)

Front 12

Superficial thrombophlebitis

Back 12

Conservative management: NSAIDs/heat/compression stockings

Repeat U/S and if extending above knee then consider anticoagulation

Front 13

Phlegmasia alba dolens

Back 13

Massive DVT of deep illiofemoral system but with sparing of superifical collaterals

Milky white leg but no venous congestions

Front 14

phlegmasia cerulea dolens

Back 14

Painful inflamed blue leg with thrombosis of both deep and superficial that can progress to venous gangrene if capillaries thrombose

Front 15

Complications of DVT

Back 15

Venous insufficiency

PE

Front 16

PERC Mnemonic

Back 16

H – Hormone (estrogen) use

A – Age > 50

D – DVT or PE history (have they HAD CLOTS?)

C – Coughing blood

L – Leg swelling disparity

O – O2 sats < 95%

T – Tachycardia (>100bpm)

S – Surgery or Trauma (recent)

Front 17

PERC Exclusion criteria

Back 17

• cancer
• thrombophilia
• strong family history of thrombophilia
• beta blockers that may mask tachycardia
• patients with transient tachycardia
• patients with amputations
• patients who are massively obese and in whom leg swelling cannot be reliably ascertained
• with baseline hypoxemia in whom a pulse oximetry reading <95% is long-standing

Front 18

Hampton hump

Back 18

Pleural based wedge shaped opacification that can indication pulmonary infarction secondary to PE

Front 19

Westermark sign

Back 19

Proximal pulmonary artery dilitation with regional oligemia secondary to PE

Front 20

ECG findings suggesting PE

Back 20

Sinus tachycardia

S1Q3T3

new RBBB/RAD

Anterior (V1-V4) T wave Inversions

Front 21

Age Adjusted D-Dimer Score

Back 21

If age >50:

Age in years X 10ug/L

Front 22

Wells Criteria for PE

Back 22

Hemoptysis 1.0

Malignancy (Tx within the last 6 mo/palliative) 1.0

Previous DVT/PE 1.5

Heart rate >100 beats/min 1.5

Immobilization or surgery (within 4 wk) 1.5

Suspected DVT 3.0

An alternative diagnosis is less likely than PE 3.0

Front 23

Mnemonic for Wells Critiera for PE

Back 23

SS PERCC

Suspicious for PE (3)
Signs of DVT now (3)
Pulse >100 (1.5)
Extremity: Past DVT/PE (1.5)
Recent surgery/immob (<4wk/>3d respectively) (1.5)
Coughing up blood (1)
Cancer (1)

Front 24

Wells Score Cutoffs

Back 24

Low (<2) 7%

Moderate (2-6) 27%

High (>6) 58%

Unlikely (0-4) 13%

Likely (>4) 39%

Front 25

Rosens Algorithim to W/U Suspected PE

Back 25

Front 26

VQ Scan results and presence of PE

Back 26

Front 27

Factors that may impact accuracy of D-Dimer for PE

FALSE POSITIVE

FALSE NEGATIVE

Back 27

False-negative D-dimer
Symptoms of PE for >3 days
Small PE
Use of qualitative latex fixation tests
Anticoagulated patients

False-positive D-dimer
Cancer and malignancy
Recent surgery
Infection (eg, pneumonia, sepsis)
Pregnancy
Age >70 years
Disseminated intravascular coagulation
Trauma
Arterial thrombosis
Acute myocardial infarction
Vaso-occlusive sickle cell crisis
Acute cerebrovascular event
Unstable angina
Atrial fibrillation
Vasculitis
Superficial phlebitis

Front 28

Comparison of the Advantages and Disadvantages of CTPA vs VQ Scan

Back 28

Front 29

ROSENS APPROACH TO PE RISK STRATIFICATION AND TREATMENT

Back 29

Front 30

Indications for IVC Filter placement

Back 30

Contraindication to anitcoagulation

DVT/PE in a patient with a complication of anti-coagulant therapy

Free floating illiofemoral/caval thombosis

Possible prophylaxis for high risk of PE

Front 31

Risk Categories for PE from JAMA Thrombolysis meta-analysis

Back 31

Low risk (HD stable and no evidence of RV dysfunction)

Intermediate risk (HD stable and objective evidence of RV dysfunction)

High Risk (HD unstable and/or SPP <90)

RV Dysfunction = Cardiac biomarkers or echocardiographic evidence

Front 32

PULMONARY EMBOLISM SEVERITY INDEX (PESI)

Back 32

Front 33

SIMPLIFIED PESI RISK STRATIFICATION

Back 33

0 = Low risk (1% mortality)

1 and more = High risk (10% mortality)