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Deep vein thrombosis and pulmonary thromboembolism

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Deep vein thrombosis and pulmonary thromboembolism

  1. 1. DVT & PE Deep vein thrombosis & Pulmonary embolism
  2. 2. Deep vein thrombosis  A form of thrombophlebitis  Incidence- ~1 per 1000 persons per year  Commonly affects leg veins (L>R)- popliteal, femoral, pelvic  Virchow’s triad-  Decreased blood flow- stasis  Damage to vessel wall  Hypercoagulability  Complication-  Pulmonary embolism  Post-phlebitic syndrome
  3. 3. DVT- risk factors  Recent surgery  Hospitalization  Advanced age  Obesity  Immobilization  Thrombophilia- AT- III/protein C or S deficiency  Pregnancy  Estrogen containing OCP  Tobacco use  Prolonged economy class air travel  Cancer  Infection
  4. 4. DVT-clinical presentation  Underlying risk factors  Symptoms  Pain, swelling, redness of leg  Superficial vein dilatation  Signs  Edema, tender veins  Homan’s sign- calf pain on dorsiflexion of foot  Acute DVT may cause impaired circulation cold extremity, absent pulse, even gangrene
  5. 5. DVT- diagnosis D-dimer level- a FDP Duplex ultrasonography, with compression CT venography (iliocaval DVT)
  6. 6. DVT- management  Mostly out-patient, using LMWH  Hospitalization recommended-  B/L DVT  Extensive proximal DVT  CRI  CHF  Cancer  Recent immobility  Low body weight
  7. 7. Anticoagulation  Low molecular weight heparin (LMWH)  Fondaparinux  Unfractionated heparin- requires hospitalization & monitoring (aPTT) Dose- 80 U/kg bolus18 U/kg/hr infusionmonitor aPTT  Long-term Warfarin- at least 3 months Dose- 5 mg OD x 3 daysmonitor PT  Life-long for life-threatening/recurrent DVT  Monitor PT/INR- 2-3 times normal
  8. 8. Other Rx options  Thrombolysis for extensive proximal clot, increases risk of bleeding  Intermittent pneumatic compression- (IPC) if heparin CI or post-op.  IVC filter- reduces PE, used in patients with ICH, potentially prothrombotic
  9. 9. DVT- prevention  LMWH/UFH in hospitalised patients with risk factors for DVT  LMWH post-op.  IPC after knee/hip surgery  Elastic compression stockings during long- haul flights  Heparin/LMWH/Warfarin in at risk pregnancy  Early mobilization
  10. 10. Post-phlebitic syndrome  Occurs in ~15% patients with DVT  Consequences-  Edema  Pain  Cramps  Venous claudication  Skin pigmentation  Dermatitis  Ulceration
  11. 11. Pulmonary embolism  Commonly embolism from DVT  Risk more with proximal DVT  Risk factors- as for DVT  Clot obstructs pulmonary arterial circulation & strains right ventricle
  12. 12. PE- diagnosis  Risk factors ± DVT  Symptoms-  Mostly silent  ~15% of sudden deaths attributable to PE  May cause sudden SOB, pleuritic chest pain, hemoptysis  Signs  Tachypnea, cyanosis, pleural rub, low-grade fever  RV strain- loud P2, LPSH, raised JVP
  13. 13. PE- diagnosis  Investigations-  CBC, PT/aPTT, LFT, RFT- for R/F  CxR- mainly to rule out other pathology  ECG- tachycardia, RV strain, R/O MI  ECHO- RV dysfunction, R/O MI  D-dimer ± US- for DVT  CT pulmonary angiography- for PE Dx  V-Q scan- contrast allergy/CI
  14. 14. PE- treatment  Anticoagulation  LMWH/Fondaparinux/Heparin  Warfarin x minimum 3 months, lifelong if recurrent  Thrombolysis  PE with hemodynamic instability  PE with RV dysfunction on ECHO   Surgical thrombectomy
  15. 15. H.I.T  Heparin induced thrombocytopenia  An immune reaction to Heparin/LMWH  Paradoxical increase in arterial/venous thrombosis, with thrombocytopenia  Can occur upto 100 days after exposure  Rx-  Stop Heparin/LMWH  Anticoagulation with direct thrombin inhibitors (monitor aPTT)- lepirudin, argatroban, bivaluridin- until platelet count stabilizes  Long-term Warfarin

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