VTE Prophylaxis and Management — MCQs
Deep vein thrombosis post-operatively is diagnosed by:
All are predisposing factors of Deep Vein thrombosis, EXCEPT :
Which of the following does not cause deep venous thrombosis (DVT)?
Which of the following drugs is used for treatment of cancer associated thromboembolism?
A patient with varicose veins came to the hospital; an intern was on duty. Which test should he perform to assess the competency of deep veins?
Patient with clinical signs of DVT had tachycardia and history of bladder cancer. According to modified Well's scoring, the probability of pulmonary embolism would be :
Virchow's triad includes all except:-
About Transfusion-Related Acute Lung Injury (TRALI), all of the following are true except:
Hyperkalemia management includes all except:
A 55-year-old diabetic presents with chest pain, shortness of breath, and diaphoresis. ECG shows ST elevation. What is the next best step?
VTE Prophylaxis and Management Indian Medical PG Practice Questions and MCQs
Question 1: Deep vein thrombosis post-operatively is diagnosed by:
- A. Clinically
- B. Ascending venography
- C. USG (Correct Answer)
- D. X-ray
Explanation: ***USG*** - **Duplex ultrasonography** is the preferred and most common imaging modality for diagnosing deep vein thrombosis (DVT) due to its non-invasive nature, accessibility, and high accuracy. - It visualizes the **vein lumen** and assesses **compressibility**, a key diagnostic feature for DVT. *Clinically* - Clinical diagnosis of DVT is unreliable, as symptoms like **leg swelling, pain, and tenderness** are non-specific and can be caused by other conditions. - While clinical suspicion can warrant further investigation, it is **insufficient for definitive diagnosis**. *Ascending venography* - **Ascending venography** was once considered the gold standard but is now rarely used due to its invasive nature, use of ionizing radiation, and potential complications. - It involves injecting **radiocontrast dye** into a foot vein and taking X-rays, making it less practical for routine use compared to ultrasound. *X-ray* - **X-rays do not directly visualize veins** or blood clots and are therefore not useful for diagnosing DVT. - They may be used to rule out other causes of leg pain or swelling, such as **bone fractures** or **arthritis**, but offer no diagnostic value for DVT itself.
Question 2: All are predisposing factors of Deep Vein thrombosis, EXCEPT :
- A. Lower limb trauma
- B. Cushing's syndrome
- C. Hip surgery
- D. Subungual melanoma (Correct Answer)
Explanation: ***Subungual melanoma*** - This is a rare form of melanoma that develops under the nail, and while serious, it is **not a recognized predisposing factor for deep vein thrombosis (DVT)**. Its primary concerns are local invasion and metastasis. - Unlike conditions affecting blood clotting or endothelium, **subungual melanoma does not directly promote hypercoagulability, venous stasis, or endothelial damage** that contribute to DVT. *Lower limb trauma* - **Trauma to the lower limb** can cause **endothelial damage** to blood vessels and **venous stasis** due to immobility or swelling, both key components of **Virchow's triad** for DVT [1]. - **Fractures or severe soft tissue injuries** often necessitate immobilization and can lead to inflammation, further increasing the risk of clot formation [1]. *Cushing's syndrome* - **Cushing's syndrome** is associated with **hypercoagulability** due to increased levels of clotting factors, such as **factor VIII** and **fibrinogen**, and decreased fibrinolytic activity. - The **elevated cortisol levels** seen in Cushing's syndrome [2] can directly contribute to a prothrombotic state, significantly increasing DVT risk. *Hip surgery* - **Major orthopedic surgeries**, especially hip surgery [1], are well-known to cause significant **venous stasis** and **endothelial damage**. - **Post-operative immobility** and a generalized **inflammatory response** following surgery contribute to a high risk of DVT formation [1].
Question 3: Which of the following does not cause deep venous thrombosis (DVT)?
- A. Lower limb trauma
- B. Subungual hematoma (Correct Answer)
- C. Hip & pelvic surgeries
- D. Cushing's syndrome
Explanation: ***Subungual hematoma*** - A **subungual hematoma** is a collection of blood under the fingernail or toenail, usually caused by trauma. - It is a localized injury that **does not affect systemic coagulation** or venous blood flow, thus not increasing DVT risk. *Lower limb trauma* - **Trauma to the lower limb**, especially involving fractures or significant soft tissue damage, can lead to **venous stasis** due to immobility and direct vessel injury [1]. - This immobility and vessel damage activate the **coagulation cascade**, significantly increasing the risk of DVT [1]. *Cushing's syndrome* - **Cushing's syndrome** is characterized by **hypercortisolism**, which leads to a **hypercoagulable state**. - **Elevated cortisol levels** increase circulating procoagulant factors and decrease fibrinolytic activity, predisposing patients to DVT. *Hip & pelvic surgeries* - **Major surgeries**, particularly those involving the **hip and pelvis**, frequently cause **endothelial injury**, blood stasis, and activate the coagulation system [1]. - Patients undergoing these procedures are at a **very high risk for DVT** due to prolonged immobility and surgical trauma [1].
Question 4: Which of the following drugs is used for treatment of cancer associated thromboembolism?
- A. Direct factor Xa inhibitors
- B. Warfarin
- C. Anti-thrombin III inhibitors
- D. LMW heparin (Correct Answer)
Explanation: ***LMW heparin*** - **Low molecular weight heparin (LMWH)** is the **preferred anticoagulant for cancer-associated thrombosis** due to its superior efficacy. - It has a more predictable pharmacokinetic profile compared to unfractionated heparin and is administered subcutaneously. *Direct factor Xa inhibitors* - While effective for general venous thromboembolism (VTE) treatment, some direct oral anticoagulants (DOACs) like factor Xa inhibitors (e.g., rivaroxaban, apixaban) may be considered but have shown mixed results in comparative studies with LMWH for cancer patients, especially those with gastrointestinal cancers, presenting a **higher risk of major bleeding**. - **LMWH** remains the **first-line choice**, especially in patients with active cancer, given the evidence for its greater efficacy and safety profile in this specific population. *Warfarin* - **Warfarin** is generally **not recommended** as a first-line treatment for cancer-associated thromboembolism due to its **drug interactions**, need for frequent monitoring (INR), and slower onset of action. - Patients with cancer often have fluctuating nutritional status, hepatic dysfunction, and receive other medications that can significantly impact warfarin's effectiveness and safety. *Anti-thrombin III inhibitors* - **Antithrombin III inhibitors** (e.g., antithrombin concentrate) are primarily used in specific conditions like **hereditary antithrombin deficiency** or in cases of heparin resistance. - They are **not a standard treatment** for cancer-associated thromboembolism in the general population of cancer patients.
Question 5: A patient with varicose veins came to the hospital; an intern was on duty. Which test should he perform to assess the competency of deep veins?
- A. Ober test
- B. Thomas test
- C. Perthes test (Correct Answer)
- D. Brodie Trendelenburg test
Explanation: ***Perthes test*** - The Perthes test assesses the **patency and competency of the deep venous system** in the leg by observing changes in superficial varicosities during muscle activity. - If the varicosities diminish or disappear with ambulation and a tourniquet applied to compress superficial veins, it indicates that the **deep veins are competent** and can handle venous return. *Ober test* - The Ober test is used to assess the **tightness of the iliotibial band**, not venous competency. - It involves abducting and extending the hip while the patient lies on their side. *Thomas test* - The Thomas test evaluates for **hip flexion contracture**, especially of the iliopsoas muscle. - It is performed by having the patient lie supine and flexing one hip fully while observing the contralateral leg. *Brodie Trendelenburg test* - The Brodie Trendelenburg test is primarily used to assess the **competency of the valves of the saphenofemoral junction and perforating veins** to distinguish between superficial and deep venous insufficiency. - It involves elevating the leg, applying a tourniquet, and then observing refilling patterns of varicose veins upon standing.
Question 6: Patient with clinical signs of DVT had tachycardia and history of bladder cancer. According to modified Well's scoring, the probability of pulmonary embolism would be :
- A. Low
- B. High
- C. Intermediate (Correct Answer)
- D. Intermediate
Explanation: **Intermediate** - Clinical signs of **DVT (3 points)**, **tachycardia (heart rate > 100 bpm, 1.5 points)**, and a history of **cancer (1 point)** sum up to 5.5 points, which falls within the range for an intermediate probability (2-6 points) on the modified Well's score for PE. - The modified Well's criteria assigns specific points for risk factors and clinical findings, guiding the diagnostic approach for pulmonary embolism [1]. *Low* - A low probability for PE according to the modified Well's score is indicated by a total score of **less than 2 points** [1]. - The patient's presentation accumulates significantly more points than this threshold due to multiple contributing factors. *High* - A high probability for PE according to the modified Well's score is indicated by a total score of **greater than 6 points** [1]. - The patient's score of 5.5 points does not meet this threshold, placing them in the intermediate category.
Question 7: Virchow's triad includes all except:-
- A. Stasis of blood flow
- B. Endothelial injury
- C. Platelet thrombus (Correct Answer)
- D. Hypercoagulability
Explanation: ***Platelet thrombus*** - Virchow's triad describes the three primary categories of factors that are thought to contribute to **thrombosis**, but it does not specifically include a formed **thrombus** itself. [1] - While **platelet thrombus** formation is an outcome of an imbalance in these factors, it is not one of the predisposing conditions identified by Virchow's triad. *Stasis of blood flow* - **Stasis** refers to a reduction in the rate of blood flow, which allows clotting factors to accumulate and endothelial cells to become hypoxic, increasing the risk of **thrombosis**. [1] - This is a well-established component of Virchow's triad, explaining why factors like immobility or venous insufficiency predispose to clot formation. *Endothelial injury* - **Endothelial injury** or dysfunction exposes the subendothelial collagen, leading to platelet adhesion and activation, and the initiation of the coagulation cascade. [1] - It is a critical component of Virchow's triad, often seen in conditions like **atherosclerosis** or trauma, which directly promotes thrombus formation. [2] *Hypercoagulability* - **Hypercoagulability**, or thrombophilia, refers to an increased propensity for coagulation due to genetic or acquired abnormalities in clotting factors. [1] - This imbalance in the coagulation system is a central part of Virchow's triad, leading to an exaggerated thrombotic response even in the absence of significant stasis or injury. [2] **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Hemodynamic Disorders, Thromboembolic Disease, and Shock, pp. 132-133. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. (Basic Pathology) introduces the student to key general principles of pathology, both as a medical science and as a clinical activity with a vital role in patient care. Part 2 (Disease Mechanisms) provides fundamental knowledge about the cellular and molecular processes involved in diseases, providing the rationale for their treatment. Part 3 (Systematic Pathology) deals in detail with specific diseases, with emphasis on the clinically important aspects., pp. 142-143.
Question 8: About Transfusion-Related Acute Lung Injury (TRALI), all of the following are true except:
- A. Steroids have a doubtful role in management
- B. Mortality is less than 10%
- C. Signs and symptoms usually subside within 2-3 weeks of onset (Correct Answer)
- D. Supportive care is the mainstay of treatment
Explanation: ***Signs and symptoms usually subside within 2-3 weeks of onset*** - TRALI is characterized by **acute onset**, typically within 6 hours of transfusion, and symptoms often resolve within **48-96 hours**. - A resolution period of **2-3 weeks** is significantly longer than the typical course for TRALI, suggesting a different underlying process. *Supportive care is the mainstay of treatment* - **Supportive care**, including oxygen therapy and mechanical ventilation if needed, is indeed the primary treatment for TRALI. - There is no specific antidote or targeted therapy for TRALI, making symptomatic management crucial. *Steroids have a doubtful role in management* - The use of **corticosteroids** in TRALI management is **controversial** and generally not recommended. - Current evidence does not support their routine use, and they are typically reserved for specific situations or not used at all. *Mortality is less than 10%* - While TRALI is a serious complication, its **mortality rate has significantly decreased** over the years due to improved recognition and mitigation strategies, now typically ranging from 5-10%. - This statement is generally considered true in contemporary medical practice.
Question 9: Hyperkalemia management includes all except:
- A. Insulin drip
- B. MgSO4 (Correct Answer)
- C. Salbutamol nebulisation
- D. Calcium gluconate
Explanation: ***MgSO4*** - **Magnesium sulfate (MgSO4)** is primarily used to treat **hypomagnesemia** and certain arrhythmias like **Torsades de Pointes**, and for seizures in preeclampsia. - It does **not have a direct role** in the acute management of hyperkalemia. *Insulin drip* - **Insulin** (often given with glucose) actively drives potassium **into cells**, thereby lowering serum potassium levels [1]. - This is a common and effective temporary measure for **hyperkalemia**, especially in urgent situations. *Salbutamol nebulisation* - **Salbutamol**, a **beta-2 agonist**, stimulates the cellular **Na-K ATPase pump**, leading to a shift of potassium from the extracellular to the intracellular space [1]. - It provides a **rapid, albeit temporary**, reduction in serum potassium levels. *Calcium gluconate* - **Calcium gluconate** does not lower serum potassium levels but rather **stabilizes the cardiac membrane**, protecting the heart from the adverse effects of hyperkalemia [1]. - It is crucial for preventing **life-threatening arrhythmias** in severe hyperkalemia [1].
Question 10: A 55-year-old diabetic presents with chest pain, shortness of breath, and diaphoresis. ECG shows ST elevation. What is the next best step?
- A. PCI (Correct Answer)
- B. Nitroglycerin
- C. Thrombolysis
- D. Heparin
Explanation: ***PCI*** - Percutaneous coronary intervention (PCI) is the **preferred reperfusion strategy** for ST-elevation myocardial infarction (STEMI) if it can be performed within 90 minutes (door-to-balloon time) at a PCI-capable hospital, or within 120 minutes if requiring transfer [1]. - This patient's symptoms (chest pain, shortness of breath, diaphoresis) and **ST elevation on ECG** indicate an acute STEMI, making PCI the most effective and definitive treatment [1]. *Nitroglycerin* - While nitroglycerin can help alleviate chest pain by causing **vasodilation** and reducing cardiac preload and afterload, it does not address the underlying coronary artery occlusion in STEMI. - It is often used as an adjunct, but not as the primary or definitive treatment for **reperfusion** in STEMI. *Thrombolysis* - Thrombolysis is an alternative reperfusion strategy for STEMI, primarily used when **primary PCI is not available** within the recommended timeframes [1]. - Given that PCI is typically available and preferred for STEMI, thrombolysis is considered a second-line option due to higher risks of bleeding and potential for re-occlusion compared to PCI [1]. *Heparin* - Heparin is an **anticoagulant** used in STEMI management to prevent further clot formation and propagation. - It is an important adjunctive therapy, but it does not directly restore blood flow to the ischemic myocardium by dissolving or mechanically removing the occluding thrombus like PCI or thrombolysis.
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