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33 Cards in this Set

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Risk factors for PE from PIPOED II Study

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


Vichows Triad

Inherited Risk Factors for PE

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

Deep Venous System of Lower Extremity

Calf (distal DVT)


-Anterior tibial


-Posterior tibial


-Peroneal



Thigh (proximal DVT)


- Polpiteal vein


- Superificial/deep femoral vein


- External Illiac Vein

Superficial venous system of lower extremity

Greater/Lesser saphenous veins


Perforating veins

Differential Diagnosis of DVT

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)

Wells Score for DVT

- 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)

Mnemonic for Wells DVT Rule

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


Risk categories and probability of DVT in validation study

Low (-2 to 0) = 3%


Moderate (1 to 2) = 17%


High (3 or more) = 75%

DVT WORK-UP ALGORITHIM INCORPORATING WELLS SCORE

Long term Anti-coagulation

- 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)


Superficial thrombophlebitis

Conservative management: NSAIDs/heat/compression stockings



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

Phlegmasia alba dolens

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



Milky white leg but no venous congestions

phlegmasia cerulea dolens

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

Complications of DVT

Venous insufficiency


PE

PERC Mnemonic

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)

PERC Exclusion criteria


  • 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

Hampton hump

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

Westermark sign

Proximal pulmonary artery dilitation with regional oligemia secondary to PE

ECG findings suggesting PE

Sinus tachycardia


S1Q3T3


new RBBB/RAD


Anterior (V1-V4) T wave Inversions

Age Adjusted D-Dimer Score

If age >50:



Age in years X 10ug/L

Wells Criteria for PE

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

Mnemonic for Wells Critiera for PE
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)

Wells Score Cutoffs

Low (<2) 7%


Moderate (2-6) 27%


High (>6) 58%



Unlikely (0-4) 13%


Likely (>4) 39%

Rosens Algorithim to W/U Suspected PE

VQ Scan results and presence of PE

Factors that may impact accuracy of D-Dimer for PE



FALSE POSITIVE


FALSE NEGATIVE

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

Comparison of the Advantages and Disadvantages of CTPA vs VQ Scan

ROSENS APPROACH TO PE RISK STRATIFICATION AND TREATMENT

Indications for IVC Filter placement

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

Risk Categories for PE from JAMA Thrombolysis meta-analysis

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

PULMONARY EMBOLISM SEVERITY INDEX (PESI)

SIMPLIFIED PESI RISK STRATIFICATION

0 = Low risk (1% mortality)


1 and more = High risk (10% mortality)