Pulmonary embolisms and DVT

What is the most common preventable cause of death among hospitalized pts?

PE

What is Virchow’s triad?

hypercoagulation, vascular damage, and venous stasis

What are some clinical risk factors for thrombus? (8)

don’t memorize, just get the idea

immobility, history of previous thromboembolic disease, estrogen (like contraceptives), pregnancy, neoplasia, CHF, deficiency of inherited factors, and acquired factors

oral contraceptives (estrogen) plus ____ leads to an increased risk of PE

smoking

incidence of a fatal PE after C-section is ____ times greater than vaginal

9x

_____ is a migratory thrombophlebitis

Trousseau sign of malignancy

What is the major inherited factor that increases risk of a PE? This is the most common cause of inherited thrombophilia

factor V Leiden

virtually all fatal emboli arise from _____ (be specific)

thrombi in the proximal leg veins (iliac, popliteal, and femoral)

What are some of the typical clinical features that are non-specific for a venous thrombi (4)

localized swelling/edema, tenderness, redness, and Homan’s sign

Embolization is at greatest risk when the clot is ____

friable; the risk decreases as the clot organizes (incorporates into the wall)

What is the most common symptom of a PE?

dyspnea

What are the 6 symptoms we usually see with a PE?

dyspnea, chest pain, anxiety, syncope or near-syncope, cough, hemoptysis

What are some things we would see on a physical exam of a pt with a PE? (6)

common: tachypnea, tachycardia, and low grade fever

less common: focal crackles, wheezing, and cyanosis

What do we expect to see on a EKG with a PE?

changes in S-T segment and T wave inversion

What EKG finding do we expect with acute right-sided compromise?

S2Q3T3 pattern and right axis deviation

What is the criteria that we use when looking at a PE diagnosis and how is it scored?

modified Wells criteria

high probability: 6+

moderate: 2-6

low: <2

What is the reference (gold) standard for diagnosing a DVT?

venography

this is “gold standard” but not typically done because its expensive, invasive, and has incidence of mortality and morbidity

What is the diagnostic test of choice for a DVT?

venous ultrasonography (doppler ultrasound)

What is a blood test that we can use for DVT?

D-dimer; this test is not very helpful if positive, but if negative then we can rule out a PE

What is the reference (gold) standard for diagnosing a PE?

pulmonary angiogram (not test of choice)

What is the diagnostic test of choice for diagnosing a PE?

CT scan IV contrast angiography

What is the treatment of choice for venous thromboembolism?

low molecular weight heparin (LMWH)

what is the most common complication of anticoagulant use?

bleeding

Coumadin needs to be bridged with ____ to prevent _____

heparin to avoid skin necrosis

What is: RV dysfunction with SBP >90

submassive PE

What is hemodynamic compromise with SBP <90, shock

massive PE

how does treatment change for a PE pt with good versus bad BP

good BP: this is likely a submassive PE, so can treat with an anticoag

bad BP: this is liekly a massive PE, you must lyse the clot

Besides pharmacotherapy, what are two other treatment approaches for thrombolytic/PE therapy?

surgical thrombectomy or vena cava interruption (with the mesh/net)