This document discusses venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism. It notes that VTE can be caused by material traveling to the lungs through the pulmonary circulation. Risk factors include surgery, pregnancy, cardiorespiratory disease, lower limb problems, malignant disease, and immobility. Symptoms range from none for small embolisms to chest pain and circulatory collapse for large embolisms. Diagnosis involves assessing risk factors and alternative causes, with tests like chest x-rays, electrocardiograms, and D-dimer levels. Treatment is anticoagulation with heparin or warfarin and supportive measures.

1. Venous Thromboembolism (VTE).

2. • Deep venous thrombosis and pulmonary
embolism (PE) can be considered as venous
thromboembolism (VTE).
• Exogenous or endogenous material that
travels to the lungs through the pulmonary
circulation,
• Causes a potential spectrum of consequences.

3. • The majority (75%) of pulmonary emboli arise
from the propagation of lower limb DVT.
• Amniotic fluid, placenta, air, fat, tumour
(especially choriocarcinoma), and
• septic emboli (from endocarditis ) are rare.

4. • PE occurs in around 1% of all patients
admitted to hospital
• Accounts for around 5% of in-hospital deaths.
• Common mode of death in patients with
cancer and stroke
• Common cause of death in pregnancy.

5. RISK FACTORS FOR VENOUS
THROMBOEMBOLISM
Surgery
• Major abdominal/pelvic surgery
• Hip/knee surgery
• Post-operative intensive care
Obstetrics
• Pregnancy/puerperium

6. Cardiorespiratory disease
• COPD
• Congestive cardiac failure
• Other disabling disease
Lower limb problems
• Fracture
• Varicose veins
• Stroke/spinal cord injury

7. • Malignant disease
• Miscellaneous
• Increasing age
• Previous proven VTE
• Immobility
• Thrombotic disorders
• Trauma

8. Pathophysiology
• The obstruction of blood flow creates alveolar
dead space
• High ventilation perfusion ratios as well as
shunting due to perfusion of atelectatic areas.
• This imbalance appears to be the principal
explanation for hypoxemia in acute PE.

9. Clinical Manifestations
• The history and physical examination are
insensitive and nonspecific for both DVT and
PE
Lower extremity venous thrombosis
• Erythema, warmth, pain, swelling, or
tenderness
• Homans' sign : pain with dorsiflexion of the
foot

10. CATEGORIES OF PULMONARY
THROMBOEMBOLI
• Acute small/medium PE
• Occlusion of segmental pulmonary artery →
infarction ± effusion
• Pleuritic chest pain, dyspnea, haemoptysis
• Tachycardia ,pleural rub, crackles, effusion
(often blood-stained)
• Low-grade fever

11. • Chest X-ray

13. Chronic PE
• Chronic occlusion of pulmonary
microvasculature, right heart failure
• Exertional dyspnoea, late symptoms of
pulmonary hypertension or right heart failure
• RV heave, loud, split P2
terminal-right heart failure
• Chest X –ray. Enlarged pulmonary artery
trunk, enlarged heart, prominent RV

14. Acute massive PE
• Major haemodynamic effects: ↓ cardiac
output; acute right heart failure
• Faintness or collapse, central chest pain,
apprehension, severe dyspnoea
• Major circulatory collapse: tachycardia,
hypotension, ↑ JVP, right ventricular gallop
rhythm, split P2 Severe cyanosis ↓ Urinary
output

15. • Usually normal, may be subtle oligaemia

16. Approch
• Is the clinical presentation consistent with PE?
• Does the patient have risk factors for PE?
• Is there any alternative diagnosis that can
explain the patient's presentation?

17. Investigations
• Chest radiography : non specific
• Important to exclude other differential
diagnosis

19. Electrocardiography
• ECG changes in PE are common but are
usually non-specific
• Useful to rule out other possible causes
D-dimer is a specific degradation product
released when fibrin undergoes endogenous
fibrinolysis
• Has a high negative predictive value and
provides a useful screening test

20. Management
• Prompt recognition and treatment is
potentially life-saving
• Supportive measures (oxygen)
Anticoagulation
• Low molecular weight heparin until INR 2-3
(five days)
• Warfarin started together with heparin
Caval filters

21. Duration of treatment
• Underlying prothrombotic risk or a history of
previous emboli
• Identifiable and reversible risk factor require
• Idiopathic VTE