Thrombophlebitis & DVT

Question 0

General Characteristics of DVT:
where does it occur?
what are risk factors?

Answer 0

DVT most often occurs in the lower extremities and pelvis.
It is associated with major surgical procedures (especially total hip replacement), prolonged bed rest, use of oral contraceptives and hormonal replacement, and inherited (factor V Leiden) and cancer associated hypercoagulable states.
increasingly air travel is being recognized as a cause.
other risk factors include, advanced age, type A blood, obesity, multiparity, inflammatory bowel disease, and lupus erythematosus.

Question 1

1. What are the general characteristics of Thrombophlebitis?
2. what is virchow’s triad?
3. Where does superficial thrombophlebitis occur?

Answer 1

1. involves partial or complete occlusion of a vein and inflammatory changes.
2. Virchow’s triad of stasis, vascular injury, and Hypercoagulability predispose a vein to development of thrombophlebitis.
3. spontaneously or following trauma and occurs frequently at the site of intravenous or peripherally inserted central catheter (PICC) lines.

Question 2

General Characteristics:

what is trousseau syndrome?

Answer 2

migratory thrombophlebitis w/ noninfectious vegetations on the heart valves (marantic endocarditis) typically in the setting of mucin secreting adenocarcinoma
-pancreatic cancer

Question 3

most common Risk factors for DVT include virchow triad 
1. venous stasis
2. endotheilia damage
3. hypercoagulation
define #3

Answer 3

hypercoagulable states =
deficiencies in antithrombin III, protein C, or protein S
Mutation in factor V gene (Factor V Leiden) or Factor II gene
Hyperhomocysteinemia

Question 4

Clinical Features:

1. superficial thrombophlebitis: symptoms? where does it most commonly occur? physical exam signs?
2. DVT:

Answer 4

1. dull pain, erythema, TENDERNESS, and induration of the involved vein or with no symptoms. most common in the long saphenous vein. A cord may be palpable following resolution of acute symptoms.
2. half of pt’s with DVT have no early signs or symptoms. Classic findings of DVT include
   * Swelling involved area with HEAT AND REDNESS over the site
   * Homan’s sign is unreliable

Question 5

Focused General Characteristics: DVT

1. where do most start?
2. w/out treatment 15-30% propagate to where?
3. What other veins in the upper extremity can lead to pulmonary embolism?

Answer 5

1. calf veins
2. proximal calf veins
3. Upper Extremity DVT = Subclavian & Axillary vein thrombosis can lead to Pulmonary Embolism in about 30% of pt.

Question 6

Upper Extremity DVT occurs in DVT of subclavian & axillary veins, and has the same risk factors as lower extremity DVT, but with SOME ADDED.
describe the added risk factors.

Answer 6

1. traumatic damage of the vessel intima from
   -heavy exertion such as **Rowing **Wrestling **Weight Lifting
   (Paget-Schroetter Syndrome)
2. from extrinsic compression at the level of the thoracic inlet (thoracic outlet obstruction)
3. insertion of central venous catheters or pacemakers

Question 7

What is clinical features are specific to upper extremity DVT?

Answer 7

Superior Vena Caval Syndrome:
facial swelling, blurred vision, dyspnea

*this is progressive occlusion of the SVC; bronchogenic cancer is leading cause; patient may complain of fullness of the head, tightness of shirt collars, necklaces, rings. Cerebral and central nervous system edema may cause headache, visual disturbance, and impaired consciousness. skin is purple and taunt

Question 8

What is Thoracic Outlet Syndrome?

Answer 8

a group of disorders that occur when the blood vessels or nerves in the space between your collarbone and your first rib (thoracic outlet) become compressed.
This can cause UNILATERAL arm pain w/ hand weakness
**shoulder,neck,and numbness in fingers

Question 9

Laboratory Findings for DVT!!!

1. what is the preferred study for DVT?

Answer 9

1. Duplex Ultrasound is the preferred study for DVT. Negative results in a patient with a high suspicion for DVT indicate the need for further study.

Question 10

Laboratory Studies:

1. What is the preferred study for DVT?
2. What is the most accurate method for definitive diagnosis?
3. What degradation product is used for diagnosis of DVT?

Answer 10

1. Duplex Ultrasonography is the preferred study for DVT. Negative results in a patient with a high suspicion for DVT indicates the need for further study.
2. Venography is the most accurate method for definitive diagnosis of DVT, but is associated with increased risk and rarely is needed
3. D-Dimer is a fibrin degradation product that is elevated in the presence of thrombus. An elevated D-dimer does not sufficiently diagnose thrombophlebitis; most hospitalized patients will have an elevated level. A negative D-dimer test (<500 ng/dL), however suggests that ultrasonography may be omitted.

Question 11

radial pulses weaken durin ginspiration and during extension of the arm of the affected side while rotating the head to the same side

Answer 11

Adson Test

-DVT

Question 12

Radial pulses become weaker and painful symptoms are reproduced while abducting the shoulder of the affected side with the humerus externally rotated

Answer 12

Wright Test

Question 13

WHich test when diagnosis DVT is HIGHLY SENSITIVE but not very specific?

Answer 13

D-Dimers

–helps to rule out a DVT w/ pt. not rule in

Question 14

Which test in diagnosing DVT and can be elevated due to other causes?

Answer 14

D-Dimers

Helps to RULE OUT DVT w/pt not rule in

Question 15

What is used to demonstrate the presence of a blood clot or noncompressibility of the affected veins PROXIMAL to the site of the occlusion?

Answer 15

Duplex Ultrasound

-great senstitivy for proximal DVT 90-100%…. than distal DVT (40-90%)

Question 16

What is helpful in the dx of upper extremity DVT and pelvic vein thrombosis?

Answer 16

MR angiography

Question 17

What is the GOLD STANDARD in DVT diagnosis?

Answer 17

Contrast Venography

• invasive and technically difficult with edematous extremities
• reserved for patients w/high clinical factors despite neg or inconclusive results from noninvasive testing

Question 18

Treatment of Superficial DVT

Answer 18

bed rest, local heat, elevation of the extremity, and NSAIDS. more serious disease may require surgical interventions

Question 19

What is the prevention for DVT?

Answer 19

prevention of DVT in bedridden pt is accomplished by elevation of the foot of the bed, leg exercise, and compression hose.
in high risk pt’s, anticoagulation may be appreciated

Question 20

What is the preferred TREATMENT of DVT?

Answer 20

anticoagulation with low molecular weight heparin; heparin followed by warfarin may be used

Question 21

What dz’s are in ur differential diangosis?
a 58 year old woman presents with retrosternal chest pain for 6 hours. the pain was gradual in onset, is sharp in nature, radiates to her neck, worsens with coughing and lying down and is relieved upon leaning forward. There is no associated nausea, diaphoresis, or dyspnea.
she was diagnosed with hypertension and diabetes 7 years ago, but are well controlled
EKG: diffuse PR segment depressions and ST segment elevations
D-Dimer = Negative
ECHO = small pericardial effusion with no signs of cardiac tamponade
Troponin T= weakly elevated
her full blood count, ESR, and renal functions are normal.
Heart = apex beat not deviated, normal heart sounds, no murmers, biphasic pericardial friction rub
Pulse = 102 bpm, regular, no pulse peradoxus
BP: 150/90
JVP: no elevated
Lungs: clear
Abdomen: no abnormalties

Answer 21

Should not have done troponin! not needed, and do not aspirate in this pt.
acute chest pain causes a wide variety of differential diagnosis: BUT in this patient the potential diagnosis are
Acute Coronary Syndrome, aortic dissection and acute pericarditis, as well as non cardiac causes such as acute pulmonary embolism and pneumothorax

Question 22

Differentiate between the patient’s diagnosis being acute coronary syndrome (ACS), aortic dissection, or acute pericarditis.

Answer 22

Points in favor of ACS = diabetes & hypertension, which are risk factors for ischemic heart disease. However the lack of history of angina is against this diangosis, as is the pleuritic nature of the pain.
Aortic Dissection is unlikely the diagnosis, as the pain is typically catastrophic in onset. In addition, many patients describe the pain as “tearing” in nature, while there often are associated with symptoms secondary to involvement of other organs (such as nervous system)

Question 23

Why would this diagnosis be acute pericarditis?

Answer 23

the pain of acute pericarditis is characteristically postural (as lying down causes the heart to rest upon the posterior pericardium, which bending forward relieves it, as in this patient. In addition the presence of a FRICTION RUB is further supportive of the diagnosis