VTE VENOUS THROMBOEMBOLISM

ALMANA GROUP OF HOSPITALS
VENOUS THROMBOEMBOLISM
VTE
DAMMAM
Dr. AHMED ELAMIN AWADELKARIM
MEDICAL RESIDENT
AHMEDELAMINELSIDDIG

OBJECTIVES
 Overview of VTE.
 Risk factors.
 Scoring systems.
 DVT diagnosis and management.
 PE diagnosis and management.
 Special situations.

overview
Medical education does not exist to provide students with
away of making living, but to ensure the health of the
community.
Rudolf Calr Virchow

DVT
Classic symptoms includes:
oUnilateral Limb pain and tenderness this may be along the line of the
vein.
oGeneralized swelling (edematous) of the calf/thigh (unilateral).
oHot, erythematous skin.
oThere may also be distension of the superficial veins.
Internal Medicine Dpt.

Well’s score for DVT

DIFFERENTIAL DIAGNOSIS
•Muscle strain/hematoma
•Popliteal cyst
•Lymphedema
•Cellulitis
•Fracture
•Chronic venous insufficiency
•Proximal venous compression (e.g. tumor)
•Congestive heart failure

D-DIMER
negative- DVT is highly unlikely (High sensitivity).
However
positive- it DOES NOT CONFIRM DVT
may be raised in patients with liver disease
rheumatoid disease
Inflammation
Cancer
Trauma
pregnancy
recent surgery

Nice guidance
for DVT

Pulmonary Embolism P.E

OVERVIEW
600.000 case per year.
50.000 deaths per year.
Tests is done too much …negative.
Most of cases are missed ….autopsy.

IN ADDITION PREVIOUS DVT

OVERVIEW
Clot travels from deep veins, RV then pulmonary arteries
Blood flow obstructed
Tissue necrosis
Symptoms result

PRESENTATION
Shortness of breath
Chest pain (+/- pleuritic)
Syncope
Hemoptysis
May mimic pneumonia (if lung infarction)
Tachycardia
Hypoxia
Elevated JVP (or distended jugular veins)
DVT symptoms

WELL’S SCORE FOR PE

NICE
GUIDANCE
FOR PE

ABGs
hypoxemia and hypocapnea (respiratory alkalosis) due to
hyperventilation,
keep in mind arterial blood gas analysis is NOT useful in
diagnosis of pulmonary embolism.
Classic finding: hypoxemia and hypocapnea (respiratory
alkalosis).
Normal ABG: 18% will have PaO2 > 85 mm Hg.
Mixed Acidosis: in setting of hemodynamic collapse.

Blood Investigations
FBC (Check WCC)
CRP
U&Es (check for any signs of electrolyte imbalance or kidney failure
which may prevent CTPA)
LFTs (check for liver failure that may cause bleeding abnormalities of be
a sign of cancer)
coagulation screen
Troponins could also be considered.

ECG CHANGES
• sinus tachycardia
• Complete or incomplete RBBB (tall R wave in V1 ‘M’; slurred S wave in V6
‘W’;MaRRoW)
• Right ventricular strain- T wave inversions in right (v1-4) and inferior (II, III,
aVF) leads
• Right axis deviation (negative QRS in lead I and aVL and positive in lead III
and aVF)
• right ventricular dilation (Dominant R wave in V1 )
• Right atrial enlargement (P pulmonale) (>2.5mm peaked P waves in inferior
leads (II, III and aVF) and >1.5mm peaked P wave in V1 and V2)
• S1Q3T3 pattern: deep S wave in lead I, Q wave in III, and inverted T wave in
lead III.

SINUS TACHY+RBBB+T INVERSION V1-3

RBBB+S1Q3T3+R axis deviation

chest x-ray
NORMAL
HAMPTON’S SIGN
WESTERMARK’S SIGN

VQ SCAN

Management

Management
Should I start??
Which one??
Appropriate dose??
How I monitor??
How long??
Patient is stable or not??

Management
For massive PE, thrombolyse unless there are any contraindications
Alteplase 50mg stat IV (if imminent cardiac arrest) or 10mg stat IV then
90mg infusion over 120mins
Contraindications include
Major surgery/trauma in previous 2 weeks; aortic dissection; acute
internal bleeding; known cerebral tumour; hx of cerebral
bleed/AVM; prolonged/traumatic CPR; pregnancy
Relative CI include BP>180/110mmHg; severe renal/liver failure;
INR>1.5 from warfarin use or liver disease; current use of warfarin
with unknown INR; current use of rivaroxiban; stroke/TIA in last 12
months

Management
Newer agents (mainly factor Xa inhibitors e.g. rivaroxaban) are now
being used in treating DVT/PE
15mg BD for 3 weeks then 20mg BD until 3 or 6 months
(provoked/unprovoked respectively(
Not used if eGFR<30
not used for >12 months – consider warfarin in those requiring longer
term anticoagulation
Offer low molecular weight heparin injection e.g. dalteparin (usually
10000-15000 units per day- based on weight), (or fondaparinux) to
those unsuitable for rivaroxiban

Management
Also, unfractionated heparin may be preferred in patients with severe
renal failure or are haemodynamically unstable.
Continue for 5 days or until the INR has been >2 for at least 24 hours
(whichever is longer).
In patients with cancer, ideally LMWH should be continued for 6
months
Offer a vitamin K antagonist e.g. warfarin, within 24 hours and continue
for 3 months minimum. (see warfarin prescribing)
Reassess risk at 3 months- consider further 3 months, particularly if the
DVT/PE was unprovoked

PREVENTION
AGH POLICY

THANK YOU
FOLLOW AHMEDELAMINELSIDDIG

VTE VENOUS THROMBOEMBOLISM

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