Deep vein thrombosis (DVT), is the formation of a blood clot in a deep vein, most commonly the legs.[2][a] Symptoms may include pain, swelling, redness, or warmth of the affected area. About half of cases have no symptoms. Complications may include pulmonary embolism, as a result of detachment of a clot which travels to the lungs, and post-thrombotic syndrome.[2][3]
Risk factors include recent surgery, cancer, trauma, lack of movement, obesity, smoking, hormonal birth control, pregnancy and the period following birth, antiphospholipid syndrome, and certain genetic conditions. Genetic factors include deficiencies of antithrombin, protein C, and protein S, and factor V Leiden mutation. The underlying mechanism typically involves some combination of decreased blood flow rate, increased tendency to clot, and injury to the blood vessel wall.
CARDIAC TAMPONADE ( Cardiac emergency) • Cardiac Tamponade is a life threatening complication caused by excessive accumulation of fluid in the pericardium. Or • Compression of all cardiac chambers due to excessive accumulation of pericardial fluid leading to compromised cardiac out put.
Kindly leave your comment if you found this helpful ;)
Some of the slides, i hide it from my real presentations for my own reference. Download to see all of them.
CARDIAC TAMPONADE ( Cardiac emergency) • Cardiac Tamponade is a life threatening complication caused by excessive accumulation of fluid in the pericardium. Or • Compression of all cardiac chambers due to excessive accumulation of pericardial fluid leading to compromised cardiac out put.
Kindly leave your comment if you found this helpful ;)
Some of the slides, i hide it from my real presentations for my own reference. Download to see all of them.
Its a elaborate presentation on deep vein thrombosis by surgery resident.
Inform me if any thing needed to be correction.
thank you.
Dr Syed Aftub Uddin, MBBS,CCCD, MS ( Resident)
email: aftub_16@yahoo.com
It is estimated that 20% of American women and 7% of American men suffer from venous disease. Venous disease results in symptoms such as aching, fatigue, swelling, and pain in the legs which can interfere with daily living.Cosmetic issues may affect quality of life.
At least 20% of patients with venous disease will develop leg ulcers. This presentation outlines the normal anatomy and physiology of venous drainage of the extremities as well as the common venous disorders such as varicose veins and deep vein thrombosis.
Deep vein thrombosis is a blood clotting disorder. causes of this is age above 60 yrs. cancer , obesity, prolonged standing etc. diagnostic evaluation of this doppler study, CT, MRI, etc. medical management of this blood thinner, like aspirin, stockings etc
This presentation is about Deep vein Thrombosis which includes in-depth information including anatomy and physiology, introduction, causes, pathophysiology, s/s/,management (medical and nursing) which is very important for PG and UG nurses.
Oxygen therapy has been in use for centuries. Oxygen)(O2) is gas used as a drug/medication and a such should be prescribed and administered in the right manner with regards to presenting indications for it's use[1]; which is always in the case of hypoxaemia[2]. It has side effects and specific risks, but, with objective monitoring and administration, it is a potent therapy for the patient with respiratory condition
Other indications include:
Increased work of breathing
Increased myocardial work and/or Myocardial infarction
Pulmonary hypertension[5]
Pre-oxygenation in induction and difficult intubation.
Pre and post suctioning[6]
Postoperative oxygenation especially in abdominal and chest surgeries[7]
Hyperbaric oxygen therapy indicated in decompression sickness, gas embolism, gas gangrene and carbon monoxide poisoning.
Anaemic Hypoxia : it’s benefits is limited due circulatory deficit[8].
In aerosol drug delivery.
GENERAL EXAMINATION
CLINICAL SYMPTOMS
On observation kindly check for symptoms like:
1. Decreased level of consciousness: seen in end-stage renal disease (ESRD).
2. Obvious scars: check previous abdominal surgery.
3. Pallor: Suggestive of underlying anaemia (e.g. erythropoietin deficiency).
4. Shortness of breath: may be due to pulmonary oedema secondary to advanced renal disease.
5. Oedema: typically presents as swelling of the limbs (e.g. pedal oedema) and abdomen (i.e. ascites). In the context of a renal system examination, possible causes could include nephrotic syndrome and end-stage renal disease (due to anuria).
6. Cachexia: muscle loss that is not entirely reversed with nutritional supplementation associated with end-stage renal failure due to protein-energy wasting (PEW).
7. Uraemic complexion: a yellow colour of the skin caused by uraemia in advanced chronic kidney disease.
8. Cushingoid appearance: facial puffiness and weight gain may be due to the use of high dose corticosteroids for renal transplant immunosuppression or glomerulonephritis.
he water to be used for the preparation of haemodialysis fluids needs treatment to achieve the appropriate quality. The water treatment is provided by a water pre-treatment system which may include various components such as sediment filters, water softeners, carbon tanks, micro-filters, ultraviolet disinfection units, reverse osmosis units, ultrafilters and storage tanks. The components of the system will be determined by the quality of feed water and the ability of the overall system to produce and maintain appropriate water quality.
ntubation is a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into their trachea (airway/windpipe). The tube keeps the trachea open so that air can get through. The tube can connect to a machine that delivers air or oxygen.
RAPID SEQUENCE INTUBATION:
Rapid sequence induction (RSI) is a set of actions during induction of anaesthesia in unfasted patients or patients at risk of aspiration/regurgitation of gastric contents.
INDUCTIION AGENT:
Induction agents (sedatives) are integral to the performance of rapid sequence intubation (RSI). They provide amnesia, blunt sympathetic responses, and can improve intubating conditions.
CRICHOID PRESSURE:
Cricoid pressure is applied by an assistant using the thumb and second finger; the first finger stabilizes the thumb and finger on the cricoid ring. press directly backwards at a force of 20-30 newtons against the cervical vertebrae.
endotracheal tube selection
Endotracheal tube selection for male is 8.0 and for female is 7.5
Formula for endotracheal tube children in paediatrics is
[(Age/4) + 4] for uncuffed tubes
[(Age/4) +3.5] for cuffed tubes
Immunization is defined as the procedure in which vaccine is injected into body to produce immunity against specifics diseases or it’s a process of protecting person from diseases by vaccination.
• Vaccine term was coined by Louis pasteur.
• Vaccine is a substance that is introduced into the body to prevent the disease produced by certain pathogens.
• Vaccine consists of dead pathogens or live attenuated (artificially weakened) organisms.
• The vaccine induces immunity against the pathogen, either by production of antibodies or by activation of T lymphocytes.
• Edward Jenner produced first live vaccine. He produced the vaccine for smallpox from cowpox virus.
Ventilator associated pneumonia (VAP) was defined as per the Center of Disease Control (CDC) as a pneumonia that occurs in a patient who was intubated and ventilated at the time of or within 48 h before the onset of the event. Pneumonia was identified using a combination of radiological, clinical, and laboratory criteria
Scrub typhus, also known as bush typhus, is a disease caused by a bacteria called ORIENTIA TSUTSUGAMUSHI.
Scrub typhus is spread to people through bites of infected chiggers (larval mites).
Most cases of scrub typhus occur in rural areas of Southeast Asia, Indonesia, China, Japan, India, and northern Australia. Anyone living in or travelling to areas where scrub typhus is found could get infected
Scrub typhus is not transmitted directly from person to person; it is only transmitted by the bites of vectors
Chiggers are abundant in locales with high relative humidity (60%–85%), low temperature (20°C–30°C), low incidence of sunlight, and a dense substrate-vegetative canopy.
Occupational risk is higher in farmers (aged 50–69 years), females.
The term inotropic state is most commonly used in reference to various drugs that affect the strength of contraction of heart muscle (myocardial contractility). However, it can also refer to pathological conditions. For example, enlarged heart muscle (ventricular hypertrophy) can increase inotropic state, whereas dead heart muscle (myocardial infarction) can decrease it.
Blood product transfusion and massive transfusionpankaj rana
Blood transfusion
Plastic bag 0.5–0.7 liters containing packed red blood cells in citrate, phosphate, dextrose, and adenine (CPDA) solution
Plastic bag with 0.5–0.7 liters containing packed red blood cells in citrate, phosphate, dextrose, and adenine (CPDA) solution
ICD-9-CM 99.0
MeSH D001803
OPS-301 code 8-80
MedlinePlus 000431
[edit on Wikidata]
Blood transfusion is generally the process of receiving blood or blood products into one's circulation intravenously. Transfusions are used for various medical conditions to replace lost components of the blood. Early transfusions used whole blood, but modern medical practice commonly uses only components of the blood, such as red blood cells, white blood cells, plasma, clotting factors, and platelets.
Dengue virus rarely causes death. However, the infection can progress into a more serious condition known as severe dengue or dengue hemorrhagic fever. Symptoms of dengue hemorrhagic fever include: bleeding under the skin. frequent vomiting.
Nosebleeds are very common in young children, affecting most at some time or another. From the outset, it is important to be aware that nosebleeds will often settle down on their own, sometimes requiring medical treatment, but that major underlying causes (blood clotting problems or abnormalities in the nose) are very rare.
Gastrointestinal bleeding (GI bleed), also known as gastrointestinal hemorrhage, is all forms of bleeding in the gastrointestinal tract, from the mouth to the rectum. When there is significant blood loss over a short time, symptoms may include vomiting red blood, vomiting black blood, bloody stool, or black stool.
Malignant hyperthermia (MH) is a disease that causes a fast rise in body temperature and severe muscle contractions when someone with the MH gets general anesthesia. MH is passed down through families. Hyperthermia means high body temperature.
History taking (History of Physical Examination)pankaj rana
A History of Physical Examination Texts and the Conception of Bedside Diagnosis. ... Throughout this paper we construct a difference between a “bedside diagnosis,” made when the physician and patient are in each other's presence, and a “remote diagnosis,” made when the patient and physician are separated.
In hospitals, nursing homes, and other healthcare settings, possible sources of
violence include patients, visitors, intruders, and even coworkers. Examples include
verbal threats or physical attacks by patients, a distraught family member who may
be abusive or even become an active shooter, gang violence in the emergency department,
a domestic dispute that spills over into the workplace, or coworker bullying.
The Glasgow Coma Scale (GCS) is a neurological scale which aims to give a reliable and objective way of recording the conscious state of a person for initial as well as subsequent assessment. A patient is assessed against the criteria of the scale, and the resulting points give a patient score between 3 (indicating deep unconsciousness) and either 14 (original scale) or 15 (more widely used modified or revised scale).
Cardiac tamponade
Synonyms Pericardial tamponade
Hemorragic effusion.jpg
A very large pericardial effusion resulting in tamponade as a result of bleeding from cancer as seen on ultrasound. Closed arrow - the heart; open arrow - the effusion
Specialty Cardiac surgery
Symptoms Shortness of breath, weakness, lightheadedness, cough[1]
Usual onset Rapid or more gradual[2]
Causes Cancer, kidney failure, chest trauma, pericarditis, tuberculosis[2][1]
Diagnostic method Symptoms and ultrasound of the heart[2]
Treatment Drainage (pericardiocentesis, pericardial window, pericardiectomy)[2]
Frequency 2 per 10,000 per year (US)[3]
Cardiac tamponade, also known as pericardial tamponade, is when fluid in the pericardium (the sac around the heart) builds up, resulting in compression of the heart.
Child abuse or child maltreatment is physical, sexual, or psychological maltreatment or neglect of a child or children, especially by a parent or other caregiver. Child abuse may include any act or failure to act by a parent or other caregiver that results in actual or potential harm to a child, and can occur in a child's home, or in the organizations, schools or communities the child interacts with.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
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Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
2. INTRODUCTION
• Venous thromboembolism (VTE) encompasses
deep venous thrombosis (DVT) and pulmonary
embolism (PE) and causes cardiovascular
death and disability.
• In the United States, the Surgeon General
estimates there are 100,000 to 180,000
deaths annually from PE and has declared that
PE is the most common preventable cause of
death among hospitalized patients.
4. • Superficial thrombosis is known as
thrombophlebitis or phlebitis a clot that
develop on surface of skin.
• Deep vein thrombosis is the formation of a
blood clot in one of the deep vein of the body
usually leg.
5. • Deep Venous Thrombosis Lower extremity DVT usually
begins in the calf and propagates proximally to the popliteal
vein, femoral vein, and iliac veins.
• Leg DVT is about 10 times more common than upper
extremity DVT, which is often precipitated by placement of
pacemakers, internal cardiac defibrillators, or indwelling
central venous catheters.
• Superficial venous thrombosis usually presents with
erythema, tenderness, and a “palpable cord.” Patients are at
risk for extension of the thrombosis to the deep venous
system.
8. INFLAMMATION AND PLATELET
ACTIVATION
• These microparticles contain proinflammatory
mediators that bind neutrophils, stimulating
them to release their nuclear material and
form web-like extracellular networks called
neutrophil extracellular traps.
• These prothrombotic networks contain
histones that stimulate platelet aggregation
and promote platelet-dependent thrombin
generation.
Harsh mohan, text book of pathology 6th edition, pg. 117
9. ALTERATION OF BLOOD FLOW
Turbulence means unequal flow while stasis means slowing.
i) Normally, there is axial flow of blood in which the most
rapidly-moving central stream consists of leucocytes and
red cells. The platelets are present in the slow-moving
laminar stream adjacent to the central stream while the
peripheral stream consists of most slow-moving cell-free
plasma close to endothelial layer.
ii) Turbulence and stasis occur in thrombosis in which the
normal axial flow of blood is disturbed. When blood slows
thrombi is facilitated by turbulence in the blood flow, while
stasis initiates the venous thrombi even without evidence of
endothelial injury.
Harsh mohan, text book of pathology 6th edition, pg. 117
10. Stasis
• Surgery, trauma, immobility, paresis
• Increasing age
• Pregnancy and postpartum
• Heart or respiratory failure
• Obesity
Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR,
Colwell CW, et al. Prevention of venous
thromboembolism: the seventh ACCP conference on
antithrombotic and thrombolytic therapy. Chest2004
11.
12. HYPERCOAGULABILITY OF BLOOD
• The effect of hypercoagulability on thrombosis is favoured by
advancing age, smoking, use of oral contraceptives and
obesity. Hypercoagulability may occur by the following
changes in the composition of blood:
i) Increase in coagulation factors e.g. fibrinogen, prothrombin,
factor VIIa, VIIIa and Xa.
ii) Increase in platelet count and their adhesiveness.
iii) Decreased levels of coagulation inhibitors e.g. antithrombin III
Harsh Mohan, text book of pathology 6th edition, pg. 117
13. • Increasing age
• Malignancy or cancer therapy
• Oestrogen therapy (contraception or hormone
replacement)
• Acute medical illness
• Inflammatory bowel disease
• Nephrotic syndrome
• Myeloproliferative disorders
• Inherited or acquired thrombophilia
Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW,
et al. Prevention of venous thromboembolism: the seventh ACCP
conference on antithrombotic and thrombolytic
therapy. Chest2004
14. ENDOTHELIAL INJURY
• Trauma
• Surgery
• Invasive procedure may distrupt venous
integrity
• Iatrogenic cause of venous thrombosis like
CVC cause upper limb DVT.
15. PRESENTATION AND CLINICAL
EXAMINATION
• PAIN AND TENDERNESS
• SWELLING (USUALLY IN ONE LIMB)
• REDNESS
• WARMTH
• EDEMA
• CYANOSIS
• HOMANS SIGN ( dorsiflexion of foot while
knee is extended)
16.
17.
18.
19. DIAGNOSIS
• PE is known as “the Great Masquerader.”
Diagnosis is difficult because symptoms and
signs are nonspecific.
• With DVT, the most common symptom is a
cramp or “charley horse” in the lower calf that
persists and intensifies over several days.
20. • Sudden, severe calf discomfort suggests a ruptured
Baker’s cyst. Fever and chills usually cellulitis rather
than DVT.
• However, massive DVT often presents with marked
thigh swelling, tenderness, and erythema. If the leg is
diffusely edematous, DVT is unlikely. More probable
is an acute exacerbation of venous insufficiency due
to postthrombotic syndrome
21. Differential Diagnosis
• DVT
• Ruptured Baker’s cyst
• Cellulitis
• Postphlebitic syndrome/venous insufficiency
Harrison principle of internal medicine 19th edition, pg. 1367
22. D-DIMER ASSAY
• The quantitative plasma d-dimer enzyme-
linked immunosorbent assay (ELISA) rises in
the presence of DVT or PE because of the
breakdown of fibrin by plasmin. Elevation of
D-dimer indicates endogenous although often
clinically ineffective thrombolysis.
• The sensitivity of the D-dimer is >80% or DVT
(including isolated calf DVT) and >95% for PE.
23. • However, the D-dimer assay is not specific. Levels
increase in patients with myocardial infarction,
pneumonia, sepsis, cancer, and the postoperative
state and those in the second or third trimester of
pregnancy.
• Therefore, D-dimer rarely has a useful role among
hospitalized patients, because levels are frequently
elevated due to systemic illness.
24. Clinical Variable DVT Score
Active cancer 1
Paralysis, paresis, or recent cast 1
Bedridden for >3 days; major surgery <12 weeks 1
Tenderness along distribution of deep veins 1
Entire leg swelling 1
Unilateral calf swelling >3 cm 1
Pitting edema 1
Collateral superficial nonvaricose veins 1
Alternative diagnosis at least as likely as DVT -2
25. Low Clinical Likelihood of DVT if Point
Score Is Zero or Less; Moderate
Likelihood if Score Is 1 to 2; High
Likelihood if Score Is 3 or Greater
Harrison principle of internal medicine 19th edition, pg. 1366
Wells' Criteria for DVT
26. Noninvasive Imaging Modalities
• Venous ultrasonography
Ultrasonography of the deep venous system relies on loss
of vein compressibility as the primary criterion for DVT.
When a normal vein is imaged in cross-section, it readily
collapses with gentle manual pressure from the
ultrasound transducer. This creates the illusion of a
“wink.” With acute DVT, the vein loses its compressibility
because of passive distention by acute thrombus.
• The diagnosis of acute DVT is even more secure when
thrombus is directly visualized. It appears homogeneous
and has low echogenicity.
27. • The vein itself often appears mildly dilated, and
collateral channels may be absent. Venous flow
dynamics can be examined with Doppler imaging.
Normally, manual calf compression causes
augmentation of the Doppler flow pattern. Loss of
normal respiratory variation is caused by an
Obstructing DVT or by any obstructive process within
the pelvis.
28.
29. • color-flow Duplex scanning is the imaging test
of choice for patients with suspected DVT
• inexpensive,
• noninvasive,
• widely available
• Ultrasound can also distinguish other causes
of leg swelling, such as tumor, popliteal cyst,
abscess, aneurysm, or hematoma.
30. LIMITATION
• Expensive
• reader dependent
• Duplex scans are less likely to detect
nonoccluding thrombi.
• During the second half of pregnancy,
ultrasound becomes less specific, because the
gravid uterus compresses the inferior vena
cava, thereby changing Doppler flow in the
lower extremities
31. Magnetic resonance (MR) (contrast-
enhanced) imaging When ultrasound
• MR is equivocal, MR venography with
gadolinium contrast is an excellent imaging
modality to diagnose DVT
• It detects leg, pelvis, and pulmonary thrombi
and is 97% sensitive and 95% specific for DVT.
• It distinguishes a mature from an immature
clot.
• MRI is safe in all stages of pregnancy.
32. Contrast phlebography
• has virtually replaced contrast phlebography
as the diagnostic test for suspected DVT.
33. TREATMENT
Ambulation early and often (simplest and most cost
effective means to reduce risk of DVT)
Intermittent External Compression Devices:
Also called sequential compression devices or SCDs
They increase rate/velocity of venous blood and reduce
pooling in the peripheral veins
Compression should begin pre-operatively and be
continued until the patient is fully ambulatory
Anticoagulant Medication Therapy
37. Intermittent External Compression Devices:
Also called sequential compression devices or SCDs
They increase rate/velocity of venous blood and reduce pooling in the
peripheral veins
38. In nine studies comparing graduated
compression stockings with no prophylaxis,
rates of DVT were reduced from 27% to 13%,
and in seven studies the addition of the
stockings to background prophylaxis further
reduced DVT rates from 15% to 2%
Review Elastic compression stockings for prevention of deep vein
thrombosis.Amaragiri SV, Lees TA Cochrane Database Syst Rev.
2000
41. • ACCP guideline recommendations for early
mobilization are also based on small numbers
of studies and therefore subject to bias.
• Mobilization may be beneficial in reducing
pain and edema from DVTs, but larger scale
studies or patient numbers are required to
validate these outcomes.
Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, et al Antithrombotic
therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed:
American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012
Feb;141
42. Low-Molecular-Weight Heparins
• Low-Molecular-Weight Heparins These
fragments of UFH exhibit less binding to
plasma proteins and endothelial cells and
consequently have greater bioavailability, a
more predictable dose response, and a longer
half-life than does UFH. No monitoring or
dose adjustment is needed unless the patient
is markedly obese or has chronic kidney
disease.
43. • Fondaparinux Fondaparinux, an anti-Xa
pentasaccharide, is administered as a weight-based
once-daily subcutaneous injection in a prefilled syringe.
• No laboratory monitoring is required. Fondaparinux is
synthesized in a laboratory and, unlike LMWH or UFH,
is not derived from animal products.
• It does not cause heparin-induced thrombocytopenia.
• The dose must be adjusted downward for patients with
renal dysfunction.
44. Unfractionated Heparin
• UFH anticoagulates by binding to and accelerating the
activity of antithrombin, thus preventing additional
thrombus formation.
• UFH is dosed to achieve a target activated partial
thromboplastin time (aPTT) of 60–80 s. The most
popular nomogram uses an initial bolus of 80 U/kg,
followed by an initial infusion rate of 18 U/kg per h.
• The major advantage of UFH is its short half-life, which
is especially useful in patients in whom hour-to-hour
control of the intensity of anticoagulation is desired.
45. Warfarin
• This vitamin K antagonist prevents carboxylation
activation of coagulation factors II, VII, IX, and X.
• The full effect of warfarin requires at least 5 days,
even if the prothrombin time, used for monitoring,
becomes elevated more rapidly. If warfarin is
initiated as monotherapy during an acute thrombotic
illness, a paradoxical exacerbation of
hypercoagulability increases the likelihood of
thrombosis.
46. Overlapping UFH, LMWH, fondaparinux, or parenteral direct
thrombin inhibitors with warfarin for at least 5 days will nullify
the early procoagulant effect of warfarin. Warfarin Dosing In
an average-size adult, warfarin is often initiated in a dose of 5
mg. The prothrombin time is standardized by calculating the
international normalized ratio (INR), which assesses the
anticoagulant effect of warfarin.
The target INR is usually
• 2.5, with a range of 2.0–3.0. The warfarin dose is usually
titrated empirically to achieve the target INR.
47. Prevention of Venous Thromboembolism
Among Hospitalized Patients
High-risk non orthopedic surgery
• Unfractionated heparin 5000 units SC bid or tid
• Enoxaparin 40 mg daily
• Dalteparin 2500 or 5000 units daily
Harrison principle of internal medicine 19th edition, pg. 1367
48. Major orthopedic surgery
• Warfarin (target INR 2.0–3.0)
• Enoxaparin 40 mg daily
• Enoxaparin 30 mg bid
• Dalteparin 2500 or 5000 units daily
• Fondaparinux 2.5 mg daily
• Intermittent pneumatic compression (with or without
pharmacologic prophylaxis)
Harrison principle of internal medicine 19th edition, pg. 1367
49. • Medically ill patients, especially if immobilized, with a
history of prior VTE, with an indwelling central venous
catheter, or with cancer (but without active
gastroduodenal ulcer, major bleeding within 3 months,
or platelet count <50,000)
• Unfractionated heparin 5000 units bid or tid
• Enoxaparin 40 mg daily
• Dalteparin 2500 or 5000 units daily
• Fondaparinux 2.5 mg daily
Harrison principle of internal medicine 19th edition, pg. 1367
50. Harrison principle of internal medicine 19th edition, pg. 1367
• Anticoagulation contraindicated Intermittent
pneumatic compression devices (but whether
graduated compression stockings are effective
in medical patients is controversial)
51. Summary of Evidence-Based
Recommendations for VTE Prevention
Strong evidence exists for the following:
• For highest risk patients combine pharmacologic and
mechanical prevention methods:
• All patients admitted to the critical care unit must be
assessed for risk of VTE
• Most critically ill patients will require
thromboprophylaxis
• Aspirin alone should not be used for VTE prophylaxis
for any patient group
• Pharmacologic thromboprophylaxis with low dose
UFH or LMEH (SQ), fondaparinus or rivaroxaban
52. • Oral vitamin K agonists (warfarin) used to achieve a
target INR of 2.5 (INR range, 2 to 3)
• Mechanical prophylaxis: graduated-compression
stockings or intermittent pneumatic compression
devices
• Some of the patients at highest risk for VTE include
those undergoing open urologic surgery, gynecologic
surgery, or total hip or knee procedures; all trauma
patients with at least one risk factor; and medical
patients with acute heart failure or acute respiratory
failure; others included in this group are immobile
patients confined to bed who have at least one risk
factor
Kearon C, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and
Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based
Clinical Practice Guidelines. Chest.2012;141(2 suppl):e419s.