Interactive cases
34 important questions on Interactive cases
What are symtpoms of deep vein thrombosis?
warm
painful calf
swelling
shining skin
pain while walkign
In which percentage of cases with suspected deep venous thrombosis is the clinical diagnosis correct
Which imaging technique is primarily used for the diagnosis of DVT?
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What is post thrombotic syndrome?
Swollen leg
Feel heavy
Pain
varicose veins
discoloration
ulceration
postthrombic pigmentation
What is the current treatment to prevent PTS?
What are symptoms of pulmonary embolism?
pleural pain
hemoptysis
fever
shock
CT scan
What role can a chest-X-ray play in PE?
can rule out other diseases mimicking pulmonary embolism
After few days pulmonary infiltrates may be visible
What are diagnostic strategies for PE?
If you have 4 points or less a D dimer test
< 500 ng/ml geen PE
More than 4 ponits:
- CT scan or perfusion scsn
What is the current regular treatment of DVT and PE?
direct oral anticoagulatns with or without initial LMWH
How is unfractionated heparin dosed?
How is LMWH dosed?
What are vitamin K antagonists? And how are they dosed?
warfarin
Variable dosage based on INR monitoring
How can the effect of vitamin K antagonist be antagonisezd?
infusion of prothrombin conentration
infusion of plasma
How does antagonizing VKA work?
first effect after 6 hours
clear effect after 12-24 hours
More vitamin K does not act faster, but will lead eventually to more and prolonged neutralizing of the VKA effect
Intravenous vitamin K does not act substantially faster
Prothrombin complex concetnrate
- contains plasma dervied purifeid vitamin K dependent clotting factors II, VII, IX, x
What are direct oral anticoagulants?
Factor Xa-inhibitors:
- rivaroxabano
- apixaban
- edoxaban
How is the antagonizing of DOACS?
- no licencesed antidote avaiable
- supportive care (transfusion red blood cells, plasma)
- potentially prothrombin concentrate
Thrombin (IIa) inhibitor (dabigatran)
- idarucizumab
Which cancer is associated with the highest risk of venous thrombosis?
Which patients with venous thrombosis are more likely to be diagnosed with cancer in the near future?
Is treatment of venous thrombosis in cancer patients different from patients without cancer?
Several hereditary risk factors for venous thrombosis have been identified. Would you test for those defects in a patient that has developed a DVT?
What is wrong in Von Willebrands disease? Give epidemiology.
Frequency < 1 - 1%
Subdivision in types:
type 1: moderate lowering vWF
type 2: activity lower than antigen level
type 3: severe form
Normandy: less binding of factor VIIIc
Autosomal inheritance: men and women equally affected
What is the clinical presentation of VWD?
Nose bleeds
Menorrhagia
Bleeeding after trauma and surgery
Much less muscle and joint bleeds
In general a much less severe bleeding tendency than hemophilia
What is the difference between hemophlia A and B?
Hemophilia B: shortage of coagulation factor IX
No difference in clinical presentation between A and B
Frequency in 1: 10.000 in the Netherlands around 1500 patients
X-linked hereditary disease: Men are affected, woman are carriers
What symptoms in mild, moderate severe and severe hemophilia?
Moderate severe: bleeding after trauma and surgery, sometimes spontaenous bleeding
Severe: bleeding after trauma and surgeyr, spontaenous bleeding
Repeated bleeding in msucles and joints leads to joint damage and severe disability
A 20 year old woman with VWD type 1 needs extraction of a wisdom tooth. How would you treat her to prevent bleeding during surgery?
A 13 month old boy with severe hemophilia A presents with a bleed in his right knee. How to treat him?
How do you treat VWD?
Clotting factor concentrate: intermediate purity factor VIII concentrate, contains both VWF and factor VIIIIc
Plasma dervied
recombinant conentrate is available
tarnexamic acid: inhibits fibrinoolysis
What is the mode of action of tranexamic acid?
Tranexamic acid is a lysine analogue, which binds to those binding sites.
Thereferore there will not be fibrin degradaation, since plasminogen can't bind to fibrin.
How to treat hemophili?
Plasma derived or made by recombinant DNA techniques
prophylactically or on demand
What are side effects of DDAVP?
What are side effects of factor concentrates?
Development of antibodies against the factor, inhibitor
Viral infections int he past: hepatitis A, b, c, hiv
What are vitmin K antagonists?
In the netherlands phenprocoumon and acenocoumara..
There is a small therapeutic index.
The difference in the anticoagulant effect between thrombosis and bleeding is small.
Treatment with VKA has to be monitored with measurement of the INR.
The VKA inhibit the recyclling of vitamin K in the liver during syntehsis of vitamin K dependent clotting factors II< VII< IX< X
What can you do when you have bleeding dure to VKA?
small amount of oral vitamin K
vitamin K IV
prothrombin complex concentrate (II, VII, IX, X)
life threatening:
- c10 mg vitamin K intravenously
- prothromboin complex concentrate, dosage dpending on the INR and body weight
How to treat a bleed in DOAC use, XA inhibitors
give prothrombin complex
if not effective give FEIBA or NOvoseven
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