Deep vein thrombosis (DVT) and pulmonary embolism (PE), collectively referred to as venous thromboembolism (VTE), constitute a major global burden of disease.
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
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
ECG-T wave inversion , Dr. Malala Rajapaksha ,Cardiology unit,General Hospit...malala720
This is a presentation on “What are the deferential Diagnosis a clinician think of when the clinician encounter T inversions in an ECG of a patient”. This will be help full in day today clinical practice and also in academic purposes.
Ventricular tachycardia (VT) is a broad complex tachycardia originating from a ventricular ectopic focus. It is defined as three or more ventricular extrasystoles in succession at a rate of more than 120 beats per minute (bpm). Accelerated idioventricular rhythm refers to ventricular rhythms with rates of 100-120 bpm
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.
ECG-T wave inversion , Dr. Malala Rajapaksha ,Cardiology unit,General Hospit...malala720
This is a presentation on “What are the deferential Diagnosis a clinician think of when the clinician encounter T inversions in an ECG of a patient”. This will be help full in day today clinical practice and also in academic purposes.
Ventricular tachycardia (VT) is a broad complex tachycardia originating from a ventricular ectopic focus. It is defined as three or more ventricular extrasystoles in succession at a rate of more than 120 beats per minute (bpm). Accelerated idioventricular rhythm refers to ventricular rhythms with rates of 100-120 bpm
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.
Diagnosis and treatment of acute pulmonary embolism (VTE)Usama Ragab
By Dr. Usama Ragab, Zagazig Faculty of Medicine
PE may account for up to 15% of all post-operative deaths.
It is the commonest cause of death following elective surgery, and the commonest cause of maternal death.
Some slides are taken from different textbooks of medicine like Davidson, Kumar and Clark and Oxford, and some from other presentations made by respected tutors. I'm barely responsible for compilation of various resources per my interest. These resources are free for use, and I do not claim any copyright. Hoping knowledge remains free for all, forever.
Venous thromboembolism (VTE) is a disorder that includes deep vein thrombosis and pulmonary embolism. A deep vein thrombosis (DVT) occurs when a blood clot forms in a deep vein, usually in the lower leg, thigh, or pelvis.
Cancer-Associated Thrombosis.From LMWH to DOACsmagdy elmasry
Cancer-Associated Thrombosis.Risk factors for CAT. Certain types of cancer are associated with higher risk of CAT. Anticoagulant therapy for VTE in patients with cancer
Should You Use DOACs for Cancer-Associated VTE?.Criteria for DOAC use in cancer patients requiring anticoagulation .DOACs + AntiCancer agents
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
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.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
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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
Deep vein thrombosis (DVT) and Pulmonary embolism (PE)
1. Deep vein thrombosis (DVT)
and
pulmonary embolism (PE)
Major Dr. Md Aminul Haque
MD (Cardiology)
Classified Cardiologist
CMH, Dhaka
2. Introduction
• Deep vein thrombosis (DVT) and pulmonary
embolism (PE), collectively referred to as venous
thromboembolism (VTE), constitute a major global
burden of disease.
• It is associated with significant morbidity and
mortality, but potentially treatable condition.
3. Incidence
• About 10 million cases occurring every year, thereby
representing the 3rd leading vascular disease after
AMI and stroke , but a under diagnosed condition.
• Incidence is steadily increasing because of
population ageing, a higher prevalence of
comorbidities, such as obesity, heart failure and
cancer.
4. Incidence
• Incidence is higher in black people, but lower in
Asian people.
• Risk does not differ by sex, although it seems to be
2 times higher in men than in women, when VTE
related to pregnancy and Oestrogen therapy are
not considered.
5. Etiology
• 1/3 to 1/2 of VTE episodes do not have an
identifiable provoking factor and are therefore
classified as unprovoked.
• Hypercoagulability , stasis or vascular wall damage
or dysfunction.
• About 20% of all VTE are cancer related, whereas
surgery and immobilization both account for 15% of
cases.
11. Homan’s sign: Tenderness during passive
dorsiflexion of foot. It is contraindicated
due to risk of thrombus detachment and
thus embolization.
Moses sign: Tenderness on touching the
calf muscle.
Pratt’s sign: Squeezing of posterior calf
elicits pain.
12. Presentations
PE-
sudden onset of dyspnoea or
deterioration of existing
dyspnoea,
chest pain,
syncope or dizziness due to
hypotension or shock,
haemoptysis,
tachycardia or
tachypnoea.
16. D-Dimer
• High sensivity and negative predictive value.
• Low specificity.
• May be elevated in trauma, recent surgery,
haemorrhage, cancer and sepsis.
• Clinical decision rules ( Wells DVT score and Revised
Geneva scores) with negative D-Dimer rules out VTE.
• All patients with a positive D-dimer assay requires a
diagnostic imaging study.
• For patients older than 50 years age adjusted D-Dimer
threshold, defined as-
Patients age x 10 micrograms/L.
17. Compression ultrasonography ( CUS )
• CUS replaced contrast venography as the
preferred method for the diagnosis of DVT.
• Whole leg CUS- Groin to the calf
• Limited (2 point) CUS- Only the popliteal and
femoral vein.
18. Compression ultrasonography ( CUS )
• Whole leg and limited CUS are considered
equivalent in terms of safety since large
management studies show both approaches to
yield false negative results below 1 %.
• The diagnosis of pelvic or IVC DVT is challenging
with CUS and so CT/MRV considered.
24. • CT pulmonary angiography ( CTPA ) has replaced
ventilation-perfusion lung scintigraphy (VQ Scan).
• VQ Scan has a role when CTPA is contraindicated
because of severe renal insufficiency or allergy to
contrast medium and can be considered in
pregnant women and young women to reduce
radiation exposure to the breast.
• In haemodynamically unstable patients with
suspected PE who require a rapid diagnosis and
cannot undergo CTPA, bedside TTE can be used to
disclose signs of RV dysfunction, which could
justify emergency repurfusion.
25. Management
Anticoagulant therapy is the mainstay for the treatment of VTE.
3 phases-
• Acute phase- first 5-10 days.
• Maintenance phase ( 3- 6 months )- 3 months anticoagulation is
enough for patients with VTE secondary to a transient risk
factor, such as major surgery, since the annual risk of recurrence
after stopping treatment is only 1%.
By contrast, the 6 month risk of recurrence in patients with
cancer is around 8% despite treatment, which strongly supports
continuing anticoagulation as long as the cancer is active.
• Extended phase ( beyond 6 months)- In patients with
unprovoked VTE, the risk of recurrence after stopping treatment
is 10% at 1 yr and 30% at 5 yr.
26. Anticoagulant
• Heparin ( UFH / LMWH )
• Parenteral Factor Xa inhibitor ( Fondaparinux )
• Oral factor Xa inhibitors ( Rivaroxaban,
apixaban and edoxaban )
• Direct oral thrombin inhibitor ( Dabigatran )
• Vitamin K antagonist ( Warfarin )
27. Anticoagulant for VTE
Route of
administration
Renal
clearance
Half life Initial
treatment
Maintenance
treatment
Extended
treatment
UFH I/V 30% 1.5h Target APTT
1.5 times of
normal
LMWH S/C 80 % 3-4h
Fondaparinux S/C 100% 17-21h
Warfarin 0ral negligible 36h Target INR 2-3
and Heparin
for at least 5
days
Target INR 2-3 Target INR
2-3
Rivaroxaban oral 30% 7-11h 15mg bd
3weeks
20 mg od 20 mg od
Dabigatran oral 80% 14-17h Heparin for at
least 5 days
150mg bd 150mg bd
Apixaban oral 25% 8-12h 10mg bd 5mg bd 2.5mg bd
28. Anticoagulant
• LMWH are preferred over UFH because of both
superior efficacy and safety. UFH needs dose
adjustment based on APTT, whereas weight
adjusted LMWH can be given in fixed doses
without monitoring.
• However, UFH should be used in patients
undergoing thrombolysis because of its shorer
half-life, ease of monitoring and the possibility of
immediately reverse the anticoagulant effect with
protamine.
• UFH also preferred in severe renal impairment
( CCR < 30 ml/min).
29. Anticoagulant
• In patients with suspected or confirmed HIT,
heparin should be stopped immediately and
anticoagulation continued with other parenteral
anticoagulant ( Fondaparinux ).
• At least 5 days overlap with Warfarin needed for
Heparin/Fondaparinux . Discontinue when INR
>2.0. Maintain INR between 2.0-3.0.
30. Anticoagulant
• Over the past decade, direct oral thrombin
inhibitor ( Dabigatran ) and factor Xa inhibitors
( Rivaroxaban, apixaban and edoxaban ) overcome
many disadvantages of Warfarin.
• Direct oral anticoagulants have a rapid onset of
action with peak levels reached within 2-4 hrs
and a half life of about 12 hrs, which is much
shorter than Warfarin.
• They have little interaction with other
medications and food and can be given on fixed
doses without routine monitoring, hence greatly
simplifying treatment.
31. Anticoagulant
• However concurrent use of strong P-glycoprotein
inhibitors or potent cytochrome P450 3A4 inhibitors
or inducers ( eg. certain protease inhibitors,
antimycotics ant antiepilepics ) should be avoided
with direct oral anticoagulants.
• Renal clearance for direct oral anticoagulants ranges
from 27% to 80%, whereas warfarin minimally
cleared by the kidneys.
• Dabigatran and edoxaban require a 5 day lead-in
with LMWH, whereas rivaroxaban and apixaban have
been evaluated in a single-drug approach without
heparin, although a higher dose during the first 3
weeks and 7 days respectively.
32. Anticoagulant
• 6 large phase III trials showed non-inferiority of
direct oral anticoagulants compared with Warfarin in
respect to recurrent VTE and a lower risk of clinically
relevant bleeding.
• A subsequent metaanalysis confirmed these findings
and reported that direct oral anticoagulants are
associated with a significant overall 39% relative
reduction in the risk of major bleeding, including
high risk patients ( PE, aged >75 yrs, bodyweight
>100 kg, moderate renal insufficiency with CCR 30-50
ml/min).
• Given the similar efficacy, superior safety profile and
ease of use compared to Warfarin, direct oral
anticoagulants should be first-line drug for VTE.
33. Anticoagulant
• Pregnant women with VTE require treatment with
LMWH, because Warfarin and direct oral
anticoagulants cross the placental barrier and
cause fetal harm.
• However Warfarin can be safely used in
breastfeeding women, but direct oral
anticoagulants are contraindicated in these
women.
• When recurrent VTE develops in patients taking
Warfarin or direct oral anticoagulants, switch to
LMWH.
• If recurrence happen during treatment with
LMWH , a dose increase of 25% is recommended.
34. Thrombolysis
• Thrombolysis in PE did not lower mortality and
was associated with a significant 9% absolute
increase in major bleeding including a 2% higher
absolute risk of haemorrhagic stroke.
• Thrombolysis should be limited to PE associated
with haemodynamic instability.
• In selected patients with ileofemoral DVT
endovascular techniques ( catheter-directed
thrombolysis ) can be considered. It reduce the
overall incidence of post-thrombotic syndrome
after 24 months.
35. IVC filters
• IVC filters are indicated in patients who have
absolute contraindications to anticoagulation, such
as those with active bleeding or with objectively
confirmed recurrent PE despite adequate
anticoagulant treatment.
• Retrievable filters preferred over permanent filters.
36. Graduated elastic compression stockings
Graduated elastic compression stockings lower the
risk of post-thrombotic syndrome.
37. Prognosis
• About 20% of patients with PE die before diagnosis and
shortly thereafter.
• About 30% of all patients with VTE have a recurrence
within 10 years.
• Post-thrombotic syndrome develop in 20-50% of
patients with DVT.
• Chronic thromboembolic pulmonary hypertension
complicates 0.1-4.0% of PE.
38. Take Home Message
• The diagnostic work-up of suspected DVT or PE includes
the sequential application of a clinical decision rule and D-
dimer testing.
• Imaging and anticoagulation can be safely withheld in
patients who are unlikely to have VTE and have a normal
D-dimer.
• All other patients should undergo CUS in case of suspected
DVT and CT in case of suspected PE.
• Direct oral anticoagulants are first-line treatment options
for VTE because they are associated with a lower risk of
bleeding than Warfarin and are easier to use.
39. Take Home Message
• Use of thrombolysis should be limited to PE
associated with haemodynamic instability.
• Anticoagulant treatment should be continued for
at least 3 months to prevent early recurrences.
• When VTE is unprovoked or secondary to
persistent risk factors, extended treatment
beyond this period should be considered when
the risk of recurrence outweighs the risk of major
bleeding.