CLINICAL PRESENTATION (Signs and symptoms of DVT & PE are neither sensitive nor specific)
CLINICAL DECISION RULES:
Clinical variable Score
Signs and symptoms of DVT 3.0
Alternative diagnosis less likely than PE 3.0
Heart rate >100/min 1.5
Immobilisation>3 days,Surgery within 4 wks 1.5
Prior PE or DVT 1.5
High clinical likelihood of PE if the point score exceeds 4.0
ASSESSMENT OF SEVERITY OF PE
Systemic Arterial Hypotension
MODERATE TO LARGE PE:
RV Hypokinesias in Echocardiography
Normal Systemic Arterial Pressure
SMALL TO MODERATE PE:
Normal Right Heart Function
Normal Systemic Arterial Pressure
Cross linked fibrin degradation product that may be increased during acute illness or VTE.
It has a low positive predictive value and specificity – If positive, requires further evaluation.
It has high negative predictive value-If negative,it excludes DVT.
LABORATORY ASSESSMENT OF INHERITED THROMBOPHILIC STATES Prothrombin gene mutation G20210A G20210A mutation Partial protein C deficiency Partial protein S deficiency Protein C activity Protein S activity, Free protein S antigen Factor V Leiden Activated protein C resistance, if positive confirm with Factor V Leiden PCR Hyperhomocystinemia Fasting plasma homocysteine levels
LABORATORY ASSESSMENT OF ACQUIRED THROMBOPHILIC STATES ANTIPHOSPHOLIPID ANTIBODY SYNDROME LUPUS ANTICOAGULANT, ANTICARDIOLIPIN ANTIBODY, BETA 2 GLYCOPROTEIN 1 PNH RBC OR WBC FLOW CYTOMETRY FOR LOSS OF CD55,CD59 MYELOPROLIFERATIVE DISORDER JAK – 2 MUTATION
IMAGING - DVT SPECIFIC TESTING
Duplex Examination -
Compressive ultrasound performed with doppler testing
PE SPECIFIC TESTING
~ ECG,Troponin levels, Chest Radiography
~ Determine pretest probability of PE along with D-Dimer assay
CONTRAST ENHANCED SPIRAL(HELICAL) CHEST CT:
~ Relatively accurate for large(proximal) PE, but sensitivity is low for small(distal) emboli
~ Clinical suspicion that is discordant with the objective finding should lead to further testing
Requires administration of radioactive material(via both inhaled and i.v. routes)
V/Q scan can be classified as normal, non diagnostic or high probability for PE
Use of clinical suspicion improves the accuracy of V/Q scan
When both the findings are discordant, further testing should be performed
UNFRACTIONATED HEPARIN (UFH):
80 U/kg bolus followed by infusion of 18 U/kg/hr.
Continued for atleast 4-5 days and until INRs of atleast 2 are achieved on 2 consecutive days with warfarin therapy.
VKAs(Vitamin K Antagonists), Warfarin or Acenocoumarol:
Started as 5 mg PO and dose adjusted according to INR
INR should be done frequently during the first month,because multiple dose adjustments are usually necessary to achieve therapeutic INR
Once a stable dose is achieved, INR monitoring should be done atleast 4 weeks.
THROMBOLYTIC THERAPY- INDICATIONS:
Refractory Systemic Hypotension
? Right Ventricular Dysfunction
ANTITHROMBIN III INFUSION:
In patients with congenital antithrombin lll deficiency - during an acute thromotic episode
INVASIVE SPECIAL THERAPIES
1] Acute DVT states in which there is absolute contraindication to anticoagulation
2] Recurrent thromboembolic episodes
LONG TERM TREATMENT WITH VITAMIN K ANTAGONISTS FOR DVT AND PE First episode of DVT or PE secondary to a transient risk factors 3 mon Recommendation applies to both proximal and calf vein thrombosis First episode of idiopathic DVT or PE 6 – 12 mon Continuation of therapy after 6 -12 mon to be considered First episode of DVT or PE with a documented thrombophilic abnormality 6 – 12 mon Continuation of therapy after 6 -12 mon to be considered First episode of DVT or PE with documented antiphospholipid or >= 2 thrombophilic abnormality 12 mon Continuation of therapy after 12 mon to be considered
COURSE OF THE ILLNESS
His breathlessness improved, was able to walk about 100 m without breathlessness. Except for sinus tachycardia, ECG features of PE disappeared. He was discharged at request on 27.2.2009 with advice to continue acitrom and to get readmitted after 3 days for planning CT Angiogram. But he came for admission the next day itself with massive hemoptysis; cause - ?acitrom related ?massive pulmonary embolism and infarct. He was treated with vitamin K, FFP and blood transfusion; shifted to IMCU for intensive care. Evaluation revealed prolonged coagulation parameters. PT- 48 seconds, INR- 4.3. Massive hemoptysis recurred and the patient had hypoxia and altered sensorium. Despite the best possible efforts, the patient succumbed to his illness.