Dvt lesson

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Deep Vein Thrombosis
Common, Preventable, and potentially Fatal

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Disclaimer
 Who am I
W. Robert Leeper, MD
PGY IV – General Surgery and Intensive Care Medicine
Schulich School of Medicine and Dentistry
University of Western Ontario
 Why am I giving this talk?
1) My research is in DVT and PE prevention
2) It’s the last talk of the day and they heard I was ‘energetic’
3) I’m a resident so I’m very, very cheap

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Overview
 What IS a DVT/PE and WHY do I care?
 When should I SUSPECT a DVT/PE?
 How do I DIAGNOSE a DVT/PE?
 How do I PREVENT a DVT/PE?
 How do I TREAT a DVT/PE?

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What is a DVT/PE and why do I care?
 Etiology = Virchow’s Triad:
 Circulatory Stasis
 Intimal Injury
 Hypercoagulability
 Definition:
 A blood clot forming in a “deep” vein
 Usually lower extremity

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What is a DVT/PE and why do I care?
 Pulmonary Embolism:
 A blood clot that formed in a “deep”
vein and then “embolized” back to the
heart/lungs
 Commonly cited cause of the “late”
trauma death

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What is a DVT/PE and why do I care?

7. + When should I SUSPECT a DVT/PE?
First and foremost…….. BE VERY, VERY SUSPICIOUS!!!!

8. + When should I SUSPECT a DVT/PE?
 Incidence
 < 5% overall
 High Risk Injuries
 Head Injury (44%)
 Lower Limb # (52%)
 Pelvic # (37%)
 Spinal Cord Injury (15%)
LHSC Data (2002 – 2007)
 High Risk Event
 Major OR < 4h (67%)
 SCD Contraindicated (74%)
 Prolonged Immobilization (93%)
 Missed doses of LMWH (100%)
Humphrey, Parry, Girotti, Gray. Unpublished Data – Presented at TAC 2007

9. + When should I SUSPECT a DVT/PE?
 Incidence
 5 – 10 % overall
 High Risk Injuries
 Spinal Cord Injury (LEVEL I)
 Lower Limb # (LEVEL II)
 Pelvic # (LEVEL II)
 Head Injury (LEVEL II)
EAST Practice Guidelines
 High Risk Factors
 Older age (LEVEL II)
 Higher ISS (LEVEL II)
 Blood Transfusions (LEVEL II)
Rogers et al. Management of Venous Thromboembolism in Trauma Patients.
J Trauma. 53(1):142-164, July 2002.

10. + How do I DIAGNOSE a DVT/PE?
 Clinical
 Swollen, Painful, Erythematous Extremity
 SOB, pleuritic pain, tachypneia, hypoxia
 SUDDEN COLLAPSE
 Laboratory
 D-Dimer
 Blood gas, EKG, CXR
 Definitive
 US leg veins (9 to 5 test)
 VQ Scan or CT PE study (24/7 test)

11. + How do I DIAGNOSE a DVT/PE?
 Doppler US in ALL symptomatic patients
 Screening US in HIGH RISK patients
LHSC Practice
 Doppler US in ALL symptomatic patients (LEVEL I)
 Screening US in HIGH RISK patients (LEVEL III)
EAST Practice Guidelines

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How do I PREVENT a DVT/PE?
Prevention Strategies
 Early Ambulation
 Prophylactic Anticoagulation
 Mechanical Compression Devices
 IVC Filters

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How do I PREVENT a DVT/PE?
Early Ambulation
 No debate on this topic
 Level I evidence
 Multiple benefits beyond
DVT/PE prevention
 Easier said than done ?

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How do I PREVENT a DVT/PE?
Prophylactic Anticoagulation
 Typically LMWH
 Dalteparin 5000 units sc daily
 LHSC Practice
 LMWH for ALL eligible patients
 LMWH given throughout hospital stay

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How do I PREVENT a DVT/PE?
EAST Guidelines
 LMWH for specific patients (LEVEL II)
(lower extremity #, pelvic #, SCI…)
 LMWH for ISS > 9 (LEVEL III)
 LMWH specifically contraindicated with
intracranial bleeding or epidural catheter
(LEVEL III)
Prophylactic Anticoagulation

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How do I PREVENT a DVT/PE?
Mechanical Compression Devices (MCD)
 Preferred method if LMWH is contraindicated
LHSC Practice
 MCD for ALL eligible patients
EAST Guidelines
 MCD may not reduce rates of DVT/PE
(LEVEL II)
 MCD may be indicated for SCI patients
(LEVEL III)

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How do I PREVENT a DVT/PE?
IVC Filters
 What are they?
 How do they work?
 When should we use them?

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How do I PREVENT/TREAT a DVT/PE?
 IVC Filters
 Traditional Indications (LEVEL 1)
 Known DVT + contraindication to anticoagulation
 Recurrent PE while on anticoagulation
 “Extended” Indications (LEVEL II)
 Free floating clot in iliac/IVC
 Following ‘massive’ PE
 “Prophylactic” Indications (LEVEL III)
 Any high risk injury type + contraindication to anticoagulation
(SCI, Pelvic #, Extremity #, Severe closed head…)

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How do I PREVENT/TREAT a DVT/PE?
 IVC Filters – LHSC Experience
 2000 – 2008
 n = 27 filters
 Very selective utilization
 85% retrieval rate
 Impressive retrieval rate
Leeper, Gray, Kribs, Parry. Unpublished Data – Presented at ATS/TAC 2009

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How do I PREVENT/TREAT a DVT/PE?
 IVC Filters – LHSC Experience
Leeper, Gray, Kribs, Parry. Unpublished Data – Presented at ATS/TAC 2009
Indication for Placement
of IVCF in Trauma
Patients
3
(11%)
10
(37%)
14
(52%)
VTE Prophylaxis
DVT
(contraindication for
anticoagulation)
(contraindication for
anticoagulation)
PE
N = 27

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How do I PREVENT/TREAT a DVT/PE?
 IVC Filters – LHSC Experience
Leeper, Gray, Kribs, Parry. Unpublished Data – Presented at ATS/TAC 2009
Figure 2 – Indication for
Retrieval/Non Retrieval of IVCF 23 (85%)
Successfully
retrieved
2
(7%)
2
(7%)
Irretrievable due
to trapped clot
Died of Injuries
Loss to Follow Up Rate = 0%
N = 27

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How do I PREVENT/TREAT a DVT/PE?
 Treatment of Known DVT/PE
 Full Dose Anticoagulation
 IV Heparin infusion
 Fragmin at HIGH dose (200 u/kg)
 IVC Filter
 If anticoagulation contraindicated
 Thrombolytics vs Surgical Embolectomy
 Indicated for MASSIVE pulmonary embolism

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Summary – DVT/PE
DVT and PE in Trauma Patients
 Maintain a HIGH INDEX of suspicion
 Maintain a LOW THRESHOLD to investigate
 Prevention >>> Cure

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Thank you
Dr. W. Robert Leeper MD
General Surgery and Critical Care Medicine - PGY IV
Schulich School of Medicine and Dentistry
The University of Western Ontario
Rob.Leeper@gmail.com