Pathophysiology
Signs & Symptoms
Investigations
Management
Anatomy & Imaging
100
DVT only occurs in veins. PE only occurs in arteries. True or false?
True
100
What type of respiratory failure occurs in PE? Why?
Type 1 respiratory failure
V/Q mismatch, leads to impaired gas exchange, hypoxaemia
100
What is the classic ECG finding of a PE only seen in <20% of patients?
S1Q3T3
large S wave in lead I, large Q wave in lead III, and inverted T wave in lead III
100
How long is anticoagulant therapy for?
- If VTE was provoked → 3 months of anticoagulation
- If VTE was unprovoked → 6 months of anticoagulation
- If there is active cancer → 3-6 months of anticoagulation
100
Why is a chest x-ray indicated in PE?
To rule out other causes
(Blood clots will not appear on an X-Ray)
200
Name 2 causes of PE. Give the most common cause as your first answer.
DVT is the most common cause of PE
Other causes:
- Fat embolism
- Air embolism
- Amniotic fluid embolism
- Septic emboli
200
What symptoms would you suspect in a PE?
pleuritic chest pain
Dyspnoea
Haemoptysis
Tachypnoea
Features of deep vein thrombosis
200
How can you use ultrasound to identify a DVT?
Vein compression - if compresses no DVT, partial compression - DVT
200
What are the NICE recommend options for initial treatment (2 options) and what is the main alternative?
Apixaban or Rivaroxaban
Alternative: Low Molecular Weight Heparin
200
Saddle pulmonary embolism
- located at the bifurcation of the main pulmonary artery
- can lead to sudden hemodynamic collapse
300
What is Virchow's Triad?
- Venous stasis: prolonged immobilisation (e.g. bed rest >5 days, major surgery within the last 2 months, recent trauma or fracture, paralysis of the lower limb, long-haul flights), venous insufficiency of the lower limb.
- Hypercoagulable state: active malignancy, pregnancy and postnatal period, thrombophilia (e.g. antiphospholipid syndrome, factor V Leiden mutation), use of combined hormonal contraception and oral hormone replacement therapy.
- Endothelial injury: trauma, surgery, venous harvest, cigarette smoking, obesity.
300
Where do you measure calf circumference and what difference is significant?
10cm distal of the Tibial Tuberosity.
More than 3cm difference between legs is significant.
300
What value indicates a PE or DVT is likely in their respective Well's scores?
Wells score for PE > 4 = likely
Wells score for DVT 2 or more = likely
300
What is the first line treatment for long term anticoagulation for a patient with antiphospholipid syndrome?
Warfarin
300
What is this CTPA showing?
Saddle PE
400
List 7 Risk factors for a VTE?
- Immobility
- Recent surgery
- Long haul travel
- Pregnancy
- Hormone therapy with oestrogen
- Malignancy
- Polycythaemia
- Systemic lupus erythematosus
- Thrombophilia
400
What are features of a massive PE?
- Haemodynamic instability: hypotension and cardiogenic shock
- Presyncope/syncope
- Elevated jugular venous pressure (JVP)
400
List 4 other causes of a raised D-Dimer
- Pneumonia
- Malignancy
- Heart failure
- Surgery
- Pregnancy
400
According to NICE Guidelines, what is the maximum length of time an inpatient should be in hospital for before starting pharmacological prophylaxis for VTE?
14 Hours
"If using pharmacological VTE prophylaxis for medical patients, start it as soon as possible and within 14 hours of admission, unless otherwise stated in the population-specific recommendations"
400
What does this CTPA show?
Normal
500
Name 3 types of Thrombophilias that predispose patients to develop blood clots?
- Antiphospholipid syndrome
- Factor V Leiden
- Antithrombin deficiency
- Protein C or S deficiency
- Hyperhomocysteinaemia
- Prothombin gene variant
- Activated protein C resistance
500
Mr Davey Tee's has presented with a fever and swelling in their lower limb. It is warm, red and has well-demarked edges. What is your top differential?
Cellulitis
500
When should you repeat an ultrasound of the leg if the patient has a negative ultrasound but positive D-Dimer and the Wells score suggests DVT?
6-8 days
500
What treatment should be considered in patients with symptomatic iliofemoral DVT, and have symptoms lasting 14 days?
Catheter-Directed thrombolysis
500
List proximal to distal 3 deep veins of the lower limb.
