DVT

Question 1

What are the risk factors for DVT?

Answer 1

THROMBOSIS:
Thrombophilia
Hormonal (COCP, pregnancy and the postpartum period, HRT)
Relatives (family history of VTE)
Older age (>60)
Malignancy
Bone fractures
Obesity
Smoking
Immobilisation (long-distance travel, recent surgery or trauma)
Sickness

Question 2

What is the presentation of DVT?

Answer 2

Unilateral erythema warm and swelling
Pain on palpation of deep veins
Distention of superficial veins

Question 3

How is DVT measured on calf?

Answer 3

It can be differentiated from deep vein thrombosis (DVT) by the presence of a tender, and indurated superficial venous segment

Palpation of DVT is confined to calf muscles

Question 4

What is the Well’s scoring system for DVT components?

Answer 4

1 point for each:

3 different Risk factors:
*Active cancer (treatment within the last 6 months or palliative)
*Paralysis, paresis, or recent plaster immobilisation of the legs
*Recently bedridden for 3 days or more, or major surgery within the last 12 weeks
* previous DVT history

Physical features:
*Localised tenderness along the distribution of the deep venous system
*Entire leg is swollen.
*Calf swelling at least 3 cm larger than asymptomatic side
*Pitting oedema confined to the symptomatic leg
*Collateral superficial veins

Question 5

When do you deduct 2 points from well score?

Answer 5

Alternative cause is at least as likely as a DVT

Question 6

What should be done for Well’s score of 1 or less?

Answer 6

DVT is unlikely and a D-dimer should be sent
If the results cannot be obtained within 4 hours, offer interim anticoagulation whilst awaiting results

Question 7

What should be done if D-dimmer is positive?

Answer 7

Ultrasound Doppler of proximal leg veins

Question 8

What should be done for Well’s score of 2 or more points?

Answer 8

DVT is likely and an ultrasound doppler of the proximal leg veins should be done within 4 hours

Question 9

What is the first line management of DVT?

Answer 9

DOACs like apixaban and rivaroxaban

Question 10

What are second line options for DVT?

Answer 10

LMWH for 5 days with dabigatran or edoxaban

Question 11

What should be tested for unprovoked DBT?

Answer 11

consider testing for thrombophilia with antiphospholipid antibodies in patients who are stopping anticoagulation

Question 12

What prophylaxis for DVT should patients undergoing elective therapy receive?

Answer 12

Mechanical compression with a pneumatic compression device

Pharmacological with low molecular weight heparin 12 HOURS AFTER OPERATION

Question 13

When is unfractionated heparin given rather than LMWH?

Answer 13

POOR renal function

Question 14

What is the difference between unfractionated and LMWH?

Answer 14

Unfractionated is standard heparin which works acutely

LMWH has a longer duration of action

Question 15

What is superficial thrombophlebitis?

Answer 15

Superficial thrombophlebitis refers to the inflammation of superficial veins, often caused by a venous thromboembolism

Question 16

How can superficial thrombophlebitis be differentiated from DVT?

Answer 16

It can be differentiated from deep vein thrombosis (DVT) by the presence of a tender, and indurated superficial venous segment

Palpation of DVT is confined to calf muscels

Question 17

Which condition can predispose patients to venous thromboembolic events?

Answer 17

Nephrotic syndrome due to loss of proteins like antithrombin III from hypoalbuminaemia

Question 18

When presenting with symptoms of both DVT and PE what should be investigated first?

Answer 18

Duplex ultrasound for DVT

Confirmation of DVT can allow LMWH to be started

Question 19

What are important intial tests for suspected DVT/PE other than D-diner and CTPA and V/Q scan?

Answer 19

Chest X ray where normal signs is confirmatory

Electrocardiography

Question 20

When should d-dimer be avoided?

Answer 20

In pregnancy
Heart disease
Infection

Question 21

Whic score for Well’s is Doppler ultrasound arranged?

Answer 21

Well’s score over 2 DVT is likely so arrange Doppler

Question 22

Which score for PE is significant?

Answer 22

Well’s score over 4

Question 23

When to do ultrasound Doppler as investigation?

Answer 23

For Wells score of 2 or above on affected limb

Question 24

When to do D-diner as investigation?

Answer 24

For wells score below 2
-> if raised, then ultrasound Doppler is indicated

Question 25

What is used for interim coagulation?

Answer 25

Apixaban and rivaroxaban

Question 26

What is the management of DVT in patients with antiphosphopipid syndrome?

Answer 26

the recommended initial treatment is LMWH for at least 5 days, overlapped with warfarin until a therapeutic INR > 2.0 is reached

Question 27

Which drug can induce a blood clot?

Answer 27

Heparin via heparin-induced thrombocytopenia is an immune-mediated response to heparin exposure which entails an increased risk of developing venous and arterial thromboembolism. It occurs when molecules of the cytokine Platelet factor 4 (PF4) bind to heparin to form an antigen

Question 28

What is the action of untractionated heparin?

Answer 28

activates antithrombin III 3 syllables in heparin= anti thrombin III

Question 29

What is the action of LM heparin?

Answer 29

exerts its anticoagulant effect mainly by inhibiting Factor Xa

Question 30

What is given for prophylaxis of DVT?

Answer 30

For patient with major risk factor, consider anti-embolisation stockings For very high risk, specialist advice sought regarding the use of low-molecular weight heparin

Question 31

What to do for suspicion of heparin induced thrombocytopenia?

Answer 31

Calculate 4T score for pre-test probability

Question 32

What does the 4T score measure!

Answer 32

Thrombocytopenia Timing of platelet fall Thrombosis or or ther sequelae Other causes of thrombocytopenia

Question 33

How to confirm heparin induced thrombocytopenia?

Answer 33

Anti platelet factor 4 antibodies