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What thrombophilias may be screened for if indicated in a patient with a VTE
Factor V Leiden, prothrombin G20210A mutation, protein C and S deficiency, antithrombin III, anti-phospholipid antibodies, hyperhomo-cysteinemia.
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What drugs should be avoided after a VTE?
Exogenous estrogen therapy
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When is an IVC filter indicated?
Patients with contraindication to anticoagulation, a serious complication of anticoagulation, or recurrent thromboembolism despite adequate anticoag.
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When is thrombolysis indicated with a VTE
- When a patient has a massive PE and associated hemodynamic instability.
- Alteplase-100mg IV infusion over 2hrs.
- Streptokinase-250,000 IU loading dose, followed by 100,000 IU per hour for 24hrs.
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Unfractionated Heparin IV, what is the goal aPTT
1.5 to 2.5 times the control.
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What is the first priority in treating the patient with VTE?
- Heparin! Typically for 5 days until stable therapeutic INR is established with Warfarin-Enoxaparin 1mg/kg SC BID or Tinzaparin 175 anti-Xa IU/kg SC QD or
- Fondaparinux SC QD
- <50 kg- 5mg
- 50-100 kg 7.5mg
- >100 kg- 10mg
- Oral Warfarin is started simultaneously
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Wells clinical decision rule for PE
- Risk factor #of points
- Clinical s&s of DVT (3)
- Alternative dx less likely than PE (3)
- HR greater than 100 BPM (3)
- Immobilization or surgery in past 4 wks (1.5)
- Previous DVT or PE (1.5)
- Hemoptysis (1.5)
- Malginancy (1)
- Score:
- Low <2
- Moderate: 2-6
- High: >6
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Key elements of H and P for leg pain and swelling
- Immobilization (>3d in past 4wk)
- Venous dilatation
- Recent surgery
- Swelling
- Temperature difference
- Edema
- Calf pain
- Homan sign
- Local tenderness
- Erythema
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Wells clinical decision rule for DVT
- Risk Factor (1pt for each)
- Active cancer (tx ongoing within previous 6 months or palliative)
- Paralysis, paresis, or recent plaster immobilization of lower extremities
- Recently bedridden for >3days or major surgery w/in 4 weeks.
- Localized tenderness along distribution of deep venous system
- Entire leg swelling
- Calf swelling by >3cm when compared with the asymptomatic leg (measured 10cm below tibial tuberosity)
- Pitting edema(greater in symptomatic leg)
- Collateral superficial veins (nonvaricose)
- Alternative diagnosis as likely or greater than that of DVT (-2 points)
- Score:
- Low <0
- Moderate 1-2
- High >2
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Symptoms and Signs in acute PE
- Symptom: dyspnea(73%), pleuritic chest pain(66%), cough(37%), hemoptysis(13%)
- Sign: tachypnea(70%), Rales (51%), tachycardia(30%), 4th heart sound(24%), accentuated pulmonic component of 2nd heart sound (23%), circulatory collapse(8%).
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