Venous Disease - Dove

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54 Terms

1
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What is DVT?

Thrombus in deep vein involving venous VALVE CUSP & venous BRANCH POINTS of calf, thigh or pelvis

2
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What is Virchow’s triad?

Etiology of DVT including hypercoagulopathy, stasis, & endothelial damage/dysfunction

3
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What is Hypercoagulopathy?

Increased circulating tissue actvation factor & decreased plasma antthrombin and fibrinolysis (obesity, cancer)

4
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What is Stasis?

From any mechanism retarding or obstructing venous return (immobility)

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What is Endothelial damage?

Surgery, external injury, vein catheters, smoking, & HTN

6
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How does clinical presentation of DVT vary?

  • Anatomical distribution

  • Extent

  • Degree of occlusion

7
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Symptoms of DVT?

  • Absence to red massive swelling on one leg

  • Cyanosis with impending venous gangrene

8
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What are the patterns of Thrombosis?

  • Isolated calf vein (distal)

  • Femoropopliteal

  • Iliofemoral thrombosis

9
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How does limb edema present in DVT?

Unilateral or bilateral of the thrombus extends to pelvic vein

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What are the most common signs/symptoms of DVT?

  • Leg pain, leg Pain, edema, erythema, tenderness, low grade fever, & prominent superficial veins

  • Pain with passive dorsiflexion of the foot (Homan’s sign)

  • Peripheral cyanosis

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Who is most likely to have small, asymptomatic, distal, non-occlusive thrombi?

Post-op patients

12
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What is a Pulmonary embolism?

A life-threatening manifestation of venous thromboembolism that occurs when a portion of the clot from a DVT breaks off, travels to the right heart, & lodges in the pulmonary vasculature

13
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What are signs of a Pulmonary embolism?

  • Tachypnea (>20/min)

  • Tachycardia

  • Decreased breath sounds

  • Rales

  • Jugular vein distension

  • Accentuated pulmonic component of the 2nd heart sound

14
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What are symptoms of a Pulmonary embolism?

  • SOB at rest or effort

  • Pleuritic chest pain

  • Cough

  • Orthopnea - SOB while lying flat

  • Symptoms of DVT

    • Calf or thigh pain or swelling

    • Wheezing

    • Hemoptysis (coughing up blood)

15
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How do you test for Wells/simplified wells clinical scores?

  • Clinical signs and symptoms of DVT

  • Alternative diagnosis less likely

  • Heart rate >100

  • Previous DVT/PE

  • Immobilization (>3 days) or surgery in the previous 4 weeks

  • Malignancy

  • Hemoptysis

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What are biomarkers of PE?

  • D-dimer

  • Troponin

  • Natriuretic peptides

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What is D-dimer?

An EXTREMELY SENSITIVE BIOMARKER OF ACUTE PE that is formed as a result of acute thrombosis and is a fibrin degrada\on product - gold standard for acute PE

18
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What are Troponoin I & T levels?

Most sensitive & specific biomarkers of myocardial injury

19
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What are Natriuretic peptides?

Valuable in evaluating a hemodynamically significant pressure on the right ventricle due to a large PE

20
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ECG signs of PE?

  • T-wave inversion in lead V1

  • ST elevation in lead aVR

  • Atrial arrhythmias & fibrillation

21
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DDX for DVT?

  • Cellulitis

  • Baker’s cyst

  • Soft tissue injury to calf

  • Achilles tendon rupture

  • Venous HTN

  • Hypoalbuminemia

  • Abdominal/pelvic tumors

22
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DDX for PE?

  • Acute coronary syndrome

  • Stable angina

  • Acute pericarditis

  • CHF

23
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What is inherited DVT?

  • Facor V leiden

  • Prothrombin gene mutation G20210A

  • Antithrombin deficiency

  • Protein C deficiency

  • Protein S deficiency

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What is acquired DVT?

  • Cancer

  • Birth control

  • Hormone replacement therapy

  • Pregnancy

  • Obesity

  • Heparin-induced thrombocytopenia

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What is inherited PE?

  • Facor V leiden

  • Prothrombin gene muta<onG20210A

  • Antithrombin deficiency

  • Protein C deficiency

  • Protein S deficiency

  • HYPERHORMOCYSTERNIA

26
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What is acquired non-provoking PE?

  • Age

  • Venous insufficiency

  • Obesity

  • Rheumatologic disease

  • Previous venous thromboembolism

  • Antiphospholipid antibody syndrome

27
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What is acquired provoking PE?

  • Surgery/trauma

  • Cancer

  • Prolonged immobility

  • Estrogen/ pregnancy

  • What is used as an uIndwelling catheter

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What is used as an initial screening test with increased levels seven days post DVT?

D-dimer

29
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What is used to detect smaller emboli & replaced the ventilation-perfusion & pulmonary angiography?

CT scan/venography

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What is highly specific & sensitive for femoral & popliteal vein thrombosis but is only 50% sensitive for calf DVT?

Venous duplex ultrasound

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What measures changes in calf blood volume & gives false positives in pre-existing venous disease, heart failure, & PAD?

Impedence plethysmography

32
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What is an alternative to CT & has high sensitivity & specificity?

MRI/venography

33
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What is gold standard, limited by pain, phlebitis, rxn to contrast, & difficult to perform in patients with edema or are obese?

Contrast venography

34
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Treatment for DVT?

  • Anticoagulation to prevent further thrombosis, PE, post-phlebitis syndrome, & chronic thromboembolic pulmonary hypertension

  • TRANSIENT RISK usually for 3 months

  • IDIOPATHIC RISK for 3-6 months

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What are the drugs of choice for DVT?

  • Fondaparinux

  • Unfractioned heparin

  • Low molecular weight heparin

  • Dabigatran

  • Warfarin

  • Rivaroxaban, apixaban

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What is Fondaparinux?

ANTICOAGULANT medication to prevent venous thromboembolism, to treat DVT, and to improve survival following MI

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What is Unfractioned heparin?

Intravenous infusion, initial dose based on the patient’s weight followed by continuous infusion per hour - USED IN RENAL INSUFFICIENCY

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What is Low molecular weight heparin?

  • Outpa\ent treatment

  • Commonly used as bride with warfarin

  • Reduced dose in renal pa\ents

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What is Dabigatran?

Used to treat DVT and PE in adults and children 3 months of age and older who have been treated with an injectable blood thinner

40
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What is Warfarin?

Dual therapy due to delayed deple\on vitamin K dependent coagulation factors - INR Goal 2.5

41
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What is Rivaroxaban, apixaban?

Used as a monotherapy, no coagulation therapy

42
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What are non-pharmacological interventions for DVT?

  • IVC - used in patients with PROXIMAL DVT if coagulant therapy is ineffective

  • Graduated compression stockings (GCSs) - reduce risk of DVT

  • Intermittent pneumatic compression (IPC) - a garment that fits around the legs and is intermittently INFLATED AND THEN DEFLATED IN A CYCLIC MANNER with compressed air via an electrical pneumatic pump

43
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What does total hip arthroplasty & total knee arthroplasty use?

  • Low molecular weight heparin

  • Rivaroxaban, apixaban

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What does hip fracture surgery use?

  • Low molecular weight heparin

  • Unfractioned heparin

  • Fondaparinux

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What type of prophylaxis is used in non-ortho surgeries?

  • Low molecular weight heparin is preferred, but unfractioned heparin is used in patients with renal insufficiency

  • Fondaparinux used in patients with heparin induced thrombocytopenia - use for a few days or until patients can ambulate or discharge from the hospital

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Management of high risk PE - respiratory support:

  • Aggressive management of hypoxemia and hypercapnia

  • Oxygen supplementation – through nasal cannula or face mask

  • High Flow Nasal Cannula (HFNC) – non-invasive method of administering high oxygen concentration and flows

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Management of high risk PE - fluid management:

Administration of fluids for the resuscitation of patients in shock is common & prevalent

48
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Management of high risk PE - hemodynamic support:

  • Judicious fluid resuscitation

  • Inotrope/vasopressor support

  • Correction of underlying cause

49
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What pharmacological support is used for PE?

  • Vasopressors

  • Inotropes

  • Pulmonary arterial vasodilaton

50
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What are Vasopressors?

To increase SVR and eventually MAP and prevent RV ischemia

51
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What are Inotropes?

Secondary to the use of vasopressors, and is mainly aimed at resolving a low cardiac output state, after blood pressure had been stabilized

52
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What is Pulmonary arterial vasodilation?

Inhaled nitric oxide - inducing an increase in cardiac output in patients with INCREASED RIGHT VENTRICULAR AFTERLOAD

53
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What is Surgical pulmonary embolectomy (SPE)?

  • Option for patients with SUBMASSIVE PE at high risk for adverse outcomes or with contraindications to fibrinolysis

  • First-line treatment rather than as rescue therapy

54
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What are indications for Surgical pulmonary embolectomy (SPE)?

  • Contraindication to Lytic Therapy

  • Clot in Transit

  • Large PFO or ASD

  • Moderate to Severe Right Ventricular Dysfunction

  • Failed Catheter Directed or Systemic Thrombolysis