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Polytrauma part 5 (VTE)

Deep vein thrombosis (DVT) & pulmonary embolism (PE). Life-threatening complications following trauma. Incidence of 5 to 63%. Risk factors: Pelvic and lower extremity fractures,Head injury and Prolonged immobilization. DVT prophylaxis is essential in the management of trauma patients.

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Dr. Fathi Neana, MD
Chief of Orthopaedics
Dr. Fakhry & Dr. A. Al-Garzaie Hospital
January, 22 - 2019
Polytrauma
Part 5
Venous Thromboembolism
(VTE)
Polytrauma part 5 (VTE)
18 years old male
Tibial osteotomy for varus
Bone lengthening
died from VTE and PE
Venous Thromboembolism (VTE) means
Deep vein thrombosis (DVT) & pulmonary embolism (PE)
Life-threatening complications following trauma
Incidence of 5 to 63%
Risk factors
Pelvic and lower extremity fractures,
Head injury
Prolonged immobilization
Prophylaxis
DVT prophylaxis is essential in the management of trauma
patients
Currently controversies regarding the optimal VTE
prophylaxis
Venous Thromboembolism
(VTE)
Ala-al-din abu Al-Hassan Ali ibn Abi-
Hazm al-Qarshi al-Dimashqi known
as Ibn al-Nafis
Born in 1213 A.D. in Damascus moved
to Egyp in 1236 A.D. and died in 1288
A.D.
Was Arab physician mostly famous for
being the first to describe the
Pulmonary circulation of the blood
The work of Ibn al-Nafis regarding the
right sided (pulmonary) circulation
pre-dates the later work (1628) of
William Harvey‘s De motu cordiss.
Both theories attempt to explain
circulation.
Central vs. Peripheral Pumps

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Polytrauma part 5 (VTE)

  • 1. Dr. Fathi Neana, MD Chief of Orthopaedics Dr. Fakhry & Dr. A. Al-Garzaie Hospital January, 22 - 2019 Polytrauma Part 5 Venous Thromboembolism (VTE)
  • 3. 18 years old male Tibial osteotomy for varus Bone lengthening died from VTE and PE
  • 4. Venous Thromboembolism (VTE) means Deep vein thrombosis (DVT) & pulmonary embolism (PE) Life-threatening complications following trauma Incidence of 5 to 63% Risk factors Pelvic and lower extremity fractures, Head injury Prolonged immobilization Prophylaxis DVT prophylaxis is essential in the management of trauma patients Currently controversies regarding the optimal VTE prophylaxis Venous Thromboembolism (VTE)
  • 5. Ala-al-din abu Al-Hassan Ali ibn Abi- Hazm al-Qarshi al-Dimashqi known as Ibn al-Nafis Born in 1213 A.D. in Damascus moved to Egyp in 1236 A.D. and died in 1288 A.D. Was Arab physician mostly famous for being the first to describe the Pulmonary circulation of the blood The work of Ibn al-Nafis regarding the right sided (pulmonary) circulation pre-dates the later work (1628) of William Harvey‘s De motu cordiss. Both theories attempt to explain circulation.
  • 7. Venous return from the lower extremity to the heart 1- The human foot Venous pump The first step in venous return 100 mm hg 2- The calf pumping mechanism produced by contraction of the soleus and the gastrocnemius muscle 3- Thoraco abdominal pump completes the process
  • 8. Venous return from the lower extremity to the heart
  • 9. The Plantar Venus Plexus 'Foot Pump‘ AVI system 1- Simulate walking 2- DVT prophylaxis 3- Compartmental syndrome 4- Allow early operative management (was before 4 or after 14 days)
  • 10. Avoid prolonged bed rest (Fagr prayers) Early mobilization (Life is movement & movement is life) Early weight bearing (AVI system in bedridden) Restore patient independency (Psychic insult in elderly) Polytrauma management Aim & Objectives
  • 11. Non weight bearing is condemned Partial weight bearing (Immediate or Early) Full weight bearing (as soon as possible) Even in bedridden by using foot and calf pump Early weight bearing
  • 12. Polytrauma management Aim & Objectives Avoid prolonged bed rest Early mobilization Early weight bearing Restore patient independency Non weight bearing is condemned Partial weight bearing (Immediate or Early) Full weight bearing (as soon as possible Even in bedridden by using foot and calf pump
  • 17. Venous Thromboembolism (VTE) 1- Deep venous thrombosis DVT) 2- Pulmonary Embolism (PE) Venous Thromboembolism (VTE) CT pulmonary angiography Venography
  • 18. Venous Thromboembolism (VTE) CT pulmonary angiography VenographyDVT • Occur in 60% with ISS > 9 • 35% - 60% DVT with pelvic fracture PE • The Most common preventable cause of death in trauma
  • 21. Virchow Triad 1-Hypercoagulability 2- Endothelial Injury 3- Venous Stasis These factors are present in almost all Polytrauma patients
  • 22. Virchow Triad Present in almost all Polytrauma patients 1-Hypercoagulability • Tissue Thromboplastin • Activated Procoagulants • Decreased Fibrinolytic Activity • Ineffective Heparin Clearance of Activated Clotting Factors • Catecholamine Release 2- Endothelial Injury • Direct Trauma to Vein at time of Injury • Compression of the Vein Secondary to Fracture Position • Vein Manipulation at Time of Fracture Fixation 3- Venous Stasis • Immobilization • Hypotension • Venous Occlusion • Edema • Fracture Position • Tourniquet
  • 23. Prevention of deep venous thrombosis (DVT) Goals: • Reduce Clinically significant events: – PE – Post Thrombotic syndrome • Low Complication Rate • High Compliance Rate • Cost Effective Methods: 1- Mechanical (non pharmacologic) 2- Pharmacologic
  • 26. Mechanical Non Pharmacologic • Elastic Stockings • Mechanical Compression Devices • Early Mobilization • IVC Filter (PE Prophylaxis) Pharmacologic • Pentasacharides • Low Molecular Weight Heparin • Heparin • Aspirin • Warfarin • Paradaxa Prevention of deep venous thrombosis (DVT)
  • 27. Mechanical Methods • Activity • Compression Stockings • Sequential Compression Device • Pedal Pumps Mechanism of Action • Decrease Stasis ∀ ↑ Fibrinolytic Activity
  • 28. Indications • Anticoagulation Prohibited • High Risk Patients • DVT Prior to Necessary Surgery • PE Despite Anticoagulation Mechanical Methods IVC Filter Advantages • Prevents Major PE • Low Morbidity – 96% Patent – 8% Migration – 4% PE • Filter insertion in the ICU Disadvantage • Expensive • Invasive • Does not treat DVT • Venous Insufficiency • Filter Occlusion
  • 29. Penta saccharides • Selective Inhibitor of Activated Xa – Decreased DVT rate with no change in major bleeding rate compared to LMWH • Eriksson B I et al N Engl J Med 2001 – Increased risk of minor bleeding • Delay administration for several hours after surgery and removal of epidural catheter Pharmacologic Methods
  • 30. Low Molecular Weight Heparin (LMWH) • Potentiates Antithrombin III • Inhibits Factor Xa & II • Minimal effects on other Factors Pharmacologic Methods Advantages • No Monitoring • Increased Efficacy • Longer 1/2 life • Predictable Response • Lower risk of thrombocytopenia Disadvantage • Parenteral Administration • Cost
  • 32. Heparin • Heparin Potentiates Anti-Thrombin III Activity • Complex Inhibits – Thrombin (IIa), IXa, Xa • Heparin effect relative short duration – Reversed with Protamine Sulfate • Significant hemorrhage risk Pharmacologic Methods
  • 33. SQ Heparin Advantages • Low Cost • No Monitoring • Convenient • Relatively Low Incidence of Bleeding Disadvantage • Insufficient Efficacy in High Risk Patients • Unpredictable Responses • Heparin Induced Thrombocytopenia Pharmacologic Methods
  • 34. Aspirin • Inhibits cyclooxygenase • Decreases Platelet Adherence • ? Effectiveness in Musculoskeletal Trauma Venous clots not typically found to have Platelet aggregates Advantages • Oral Administration • Tolerated well • In-expensive • No Monitoring Disadvantage • ? Efficacy when used alone • GI Intolerance • Prolonged anti-platelet effect Pharmacologic Methods
  • 35. Warfarin • Blocks Vit K conversion in Liver • Effects Vit K Dependent Factors • Effects the Extrinsic Clotting System • Factor VII Effected first, Short Half Life • Monitored with Pro-Time INR 2.0 - 2.5 • Reversed With Vitamin K or FFP Advantages • Effective • Oral Administration • Inexpensive Disadvantage • Requires Monitoring • Difficult to Reverse • Increased Bleeding Complications in Elderly Pharmacologic Methods
  • 36. The clinical significance of targeting different parts of the coagulation cascade has not been established
  • 37. Pharmacologic Methods Paradaxa (dabigatran etexilate mesylate) Indications and Usage • To reduce the risk of stroke and systemic embolism in non valvular atrial fibrillation‑ • Treatment of DVT & PE in patients who have been treated with a parenteral anticoagulant for 5 10 days‑ • Reduce the risk of recurrence of DVT & • PE in patients who have been previously treated Contraindications • active pathological bleeding • known serious hypersensitivity reaction (e.g., anaphylactic reaction or anaphylactic shock) to PRADAXA • mechanical prosthetic heart valve
  • 39. • Level I Evidence Major Significance – Spinal Fracture – Spinal Cord Injury • Level II No Major Significance – Advanced Age – ISS Score – Blood Transfusion – Long Bone, Pelvis, Head Injury EAST Guidelines Guidelines based on qualitative review of the current scientific literature improve uniformity of opinion and prescribing practices Watts JBJS B 05 Deep venous thrombosis (DVT) Risk Factors
  • 40. • Physical Examination • Ascending Venography • Duplex Ultrasonography • Magnetic Resonance Venography Deep venous thrombosis (DVT) Screening
  • 41. Physical Examination • Calf Swelling • Palpable Venous Cords • Calf Pain • Homan’s Sign • All Unreliable
  • 42. Ascending Contrast Venography • Sensitive for detection • Invasive • Dye Problems (allergies, renal) • Injection Site Irritation • Poor Pelvic Vein Evaluation • Gold Standard Invasiveness, expense make ACV a poor screening tool
  • 43. Doppler / Duplex Ultrasound • Comparable to Venogram • Non Invasive • No Morbidity • Poor Axial (i.e. Pelvic) Vein Evaluation • Operator Dependent • Good Screening Tool – Noninvasive, reproducible
  • 44. Magnetic Resonance Venography • Non Invasive • Good Visualization of Pelvic Veins • Difficult in Polytrauma Patient • Excellent specificity and sensitivity for suspected DVT • Controversial for screening
  • 46. THE Most common Preventable cause of death in trauma Pulmonary Embolism PE The classic presentation Abrupt onset of pleuritic chest pain, shortness of breath & hypoxia Most patients with pulmonary embolism have no obvious symptoms at presentation Symptoms may vary from sudden catastrophic hemodynamic collapse to gradually progressive dyspnea The diagnosis of pulmonary embolism suspected in patients with respiratory symptoms unexplained by an alternative diagnosis
  • 47. Pulmonary Embolism PE Atypical symptoms and presentation • Seizures • Syncope • Abdominal pain • Fever • Productive cough • Wheezing • Decreasing level of consciousness • New onset of atrial fibrillation • Haemoptysis • Flank pain • Delirium (in elderly patients)
  • 48. Clinical Shortness of breath, agitation, confusion Laboratory ↓ PaO2, ↑ A-a gradient (Alveolar–arterial gradient Normal = (Age/4) + 4) Diagnostic studies V/Q scans (Ventilation/perfusion lung scans) Pulmonary Angiogram, CT PA (CT pulmonary angiogram) Pulmonary Embolism PE Diagnosis
  • 49. Ventilation Perfusion Scan V/Q scans • Ventilation Perfusion mismatch • Results – Low probability • 15% False Negative – Medium • Need Angiogram – High probability • 15% False Positive • Screening Tool
  • 50. Pulmonary Angiogram • Angiographic Evaluation of pulmonary vascular tree • Allows Placement of IVC Filter in same setting if indicated • Sensitive - Standard in PE Detection. Diagnostic
  • 51. CT pulmonary Angiogram CT PA Example of a CTPA A saddle embolus The white area above the center is the pulmonary artery opacified by radiocontrast Inside it, the grey matter is blood Clot The black areas on either side are the lungs, with around it the chest wall.
  • 52. • Anticoagulation • Filter - for recurrent event despite anticoagulation • Thrombectomy – Serious Acute PE – Patient in extremous – Large identifiable PE Pulmonary Embolism PE Treatment
  • 53. Venous Thromboembolism (VTE) DVT/PE Outcome • No Diagnosis and Treatment – 30% Mortality • Correct Diagnosis and Therapy – 11% Mortality in First Hour – 8% Mortality After First Hour • Post Thrombotic Syndrome – Valvular Incompetence – Venous Stasis – Edema – Cutaneous Atrophy • Recurrent DVT – 20% of Patients