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52 Cards in this Set
- Front
- Back
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What percentage of DVTs are asymptomatic?
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50 - 60%
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What are causes of venous stasis?
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• CHF, MI, stroke • Immobilizations • Obesity • Pregnancy • Varicose veins
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What is the treatment of a pregnant women with DVT?
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• Heparin is the drug of choice • can use Warfarin in 2nd or 3rd trimester only
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What are some causes of vessel injury?
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• fractures • major surgery (CABG, heart surgery) • previous DVT • trauma • venous catherization
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What are some hypercoagulable states?
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• malignancy • estrogen use • pregnancy • clotting factor abnormalities
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Give examples of clotting factor abnormalities
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• Protein C & S deficiency • Antithrombin III deficiency • Activated Protein C • Prothrombin mutations
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What are major risk factors of a venous thromboembolism (VTE)?
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• cancer • major trauma • prior VTE • surgery of the lower extremities • venous stasis
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What are signs and symptoms of a DVT?
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• pain, tenderness, cyanosis • swelling / edema • warmth • redness / erythema
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What are diagnostic tests used to evaluate for DVT?
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• Ultrasound venous doppler (noninvasive, most widely used) • Contrast venography (invasive, used in non-conclusive ultrasound)
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What percentage of pulmonary emboli originate from a DVT?
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90%
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What are signs and symptoms of PE?
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• 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
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What are basic test used to diagnose a PE?
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• arterial blood gas (ABG) • chest x-ray • EKG
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What are objective tests used to diagnose a PE?
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• V/Q scan (most common) • echo • MRI • pulmonary angiography • spiral CT
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Name 2 thrombolytics used in the treatment of a DVT or PE
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• Alteplase • Streptokinase
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True/False: Thrombolytics are the drug of choice for treating a DVT or PE
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Thrombolytics are not the drug of choice because of all the adverse effects (such as increased bleeding). The correct answer is: False
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What are anticoagulants that can be used to treat a DVT/PE?
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• Heparin • LMWH • Warfarin
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What is the mechanism of action for Heparin, LMWH, and Warfarin?
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• Heparin: immediately inhibits activity of thrombin • LMWH: immediately inhibits activity of factor Xa • Warfarin: inhibits synthesis of vitamin K dependent coagulation proteins
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True/False: Warfarin should be started at the same time as Heparin or LMWH
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Warfarin (Coumadin) should be started at the same time because it will take 2-3 days to become therapeutic The correct answer is: True
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What are baseline labs to get for a patient suspected of having a DVT / PE?
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PT, PTT, CBC, Platelets, D-Dimer * also check for contraindications
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What are imaging studies that should be done for a patient with a suspected DVT / PE?
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V/Q scan, Echo, Doppler
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What is the dosing of Heparin with a confirmed patient with a DVT / PE?
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• weight based (use actual body weight) • 70 Units/kg bolus and then 15 units/kg/hr • adjust according to PTT
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What is the dosing of Enoxaparin (Lovenox) with a patient confirmed for having a DVT / PE?
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• 1 mg/kg sc q12 hrs • if CrCl < 30 ml/min, then q24 hrs
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What is the effect of Argatroban on the INR?
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• Argatroban can falsely elevate the INR • INR goal for a patient on Argatroban will be between 5-6
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What is the dosing of Warfarin?
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• start on day 1 at 5 mg • adjust according to INR (goal 2-3) • treat for about 3 months
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What lab is used to monitor Warfarin (Coumadin)?
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INR
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When do you stop the heparin or LMWH when you're overlapping with Warfarin?
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stop after 4-5 days of combined treatment and therapeutic for at least 3 days
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What are some of the difference between Heparin & LMWH?
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• 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)
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Name the LMWH that are available
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• Dalteparin (Fragmin) • Enoxaparin (Lovenox) • Tinzaparin (Innohep)
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Why does LMWH have less monitoring?
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because you don't dose adjust according to PTT
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What are labs that can be monitored on patients on LMWH?
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• Hgb, Hct, PLT, PTT
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True/False: LMWH has a reduced incidence of heparin-induced thrombocytopenia
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The correct answer is: True
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What are adverse effects of heparin and LMWH?
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Osteopenia
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What are patients that must be on DVT prophylaxis?
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• abdominal / pelvic surgery • hip fracture / replacement • immobilzation • knee replacement • major trauma
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What is the dosing of Lovenox for DVT/PE prophylaxis?
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• Lovenox 40 mg sc Q24hrs • if CrCl < 30 ml/min, Lovenox 30 mg sc Q24hrs
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What is the dosing of Heparin for DVT/PE prophylaxis?
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• Heparin 5000 IU sc Q8hrs (or 12hrs) *no renal adjustment needed
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What are factors that should be considered when administer DVT/PE prophylaxis?
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• risk of recurrent venous thromboembolism (VTE) • risks for major bleeding • patient compliance • patient preference
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What is the recommended length of DVT/PE prophylaxis for a patient with one episode of venous thromboembolism?
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• from a 2° cause » 3 months • idiopathic » 6 months • from cancer or protein C or S deficiency » 6 months
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What is the recommended length of DVT/PE prophylaxis for a patient who has had two episodes of VTEs?
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indefinite prophylaxis treatment or filter placement
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What are risk factors for bleeding complications?
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• age > 65 • aspirin use • history of GI bleed • recent surgery • renal failure • stroke • thrombocytopenia
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What is the most common location of bleeding complications?
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GI tract and urinary tract
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What is the treatment of a patient with life-threatening bleeding that is on heparin?
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• stop heparin and revese effect with protamine sulfate • 1 mg of protamine neutralizes about 100 units of heparin
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Why must protamine be infused slowly?
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protamine can induced hypotension
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What do you do if the patient is on Warfarin and the INR is above the therapeutic range?
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discontinue warfarin
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What do you do if the patient is on Warfarin with a high INR and non-life threatening bleeding?
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Vitamin K 5-10 mg PO
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What do you do if the patient is on Warfarin with a high INR and life-threatening bleeding?
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• Vitamin K 5-10 mg SC (1 time) • +/- plasma
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Why should you not give Vitamin K if a patient is on Warfarin but not bleeding?
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will reverse anticoagulation and will have to restart anticoagulation from the beginning (will require hospitalization)
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Why should you never give Vitamin K IV?
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can cause severe hypotension
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What are complications of anticoagulants?
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• Heparin Induced Thrombocytopenia • Skin Necrosis • Hypersensitivity • Bleeding
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What are drugs that can be used to treatment HIT?
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use direct-thrombin inhibitors: • Argatroban • Angiomax (Bivalirudin)
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What are drugs that increase PT?
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• androgens (progesterone, testosterone, oral contraceptives, steroids) • thyroid hormones (synthroid, levothyroxine)
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What are drugs that decrease PT?
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• barbituates • estrogens • carbamezapine • griseolfulvin • phenytoin • rifampin
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What are alternative/herbal drugs that can be used for anticoagulation?
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• Fish Oils • Garlic • Ginko Biloba • OTC products (aspirin, NSAIDS, Pepto-Bismol, alcohol, alka-seltzer) • Vitamin E
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