Deep vein thrombosis and Pulmonary embolism 2014

PULMONARY EMBOLISM

DEEP VEIN THROMBOSIS

What is the major type of pulmonary emboli ?

Fat emboli

Air emboli

Amniotic fluid emboli

Thrombus (clot emboli)

Which of the following are clinical findins in deep vein thrombosis?

PR segment depression

Unilateral edema

Phlegmatia cerulea dolens

Palpable, indurated cord-like, tender subcutaneous venous segment

Homans’s sign –pain at dorsiflexion

DEFINITION ETIOLOGY MORPHOPATHOLOGY

CLINICS LAB TESTS PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT COMPLICATIONS

DEEP VEIN THROMBOSISWhat you should know

DEFINITION

DEFINITION:

- thrombi at the level of deep veins of the leg or even abdominal (including inferior cava vein, portal vein)

Great saphenous vein

Popliteal vein

ANATOMY

NO YES

Superficial femoral vein

Profound femoral vein

Superficial femoral vein

Profound femoral vein

ETIOLOGY

Virchow’s triad

-1) blood stasis

- 2)parietal venous lesion (endothelial damage)

-3) hypercoagulability

MORPHOPATHOLOGY

VENOUS vs ARTERIAL

CLINICS

Asymptomatic

Unilateral edema

Leg pain and tenderness

CLINICS

Homans’s sign –dorsiflexion

Lowenberg’s sign – tensiometer 60Hg

Ramirez’s sign – above knee

Lisker’s sign – veins from bone.

Louvel’s sign – caugh

Mikaelis’s sign <38,5 AB/frison

Mahler’s sign –FC.

ORTHOPEDICS

CLINICS

SEVERE FORMS:

Phlegmatia cerulea dolens-cyanotic from

massive iliofemural venous obstruction

Phlegmatia alba dolens – white from massive iliofemural+arterial compression/spasm

Phlegmatia cerulea dolens

Phlegmatia alba dolens

LAB TESTS

D-dimer

Fibrin degradation product

Elevated in any medical condition with clots:

Trauma

Recent surgery

Hemorrhage

Cancer

Sepsis

Low specifity for DVT only to rule out DVT, not to confirm

D-dimers

LAB TESTS in young patients.

Factor II

Factor V

LAB TESTS in young patientsAntithrombin III deficiency

Protein C deficiency

Protein S deficiency

Prothrombin 20210A mutation

Factor V Leiden

Homocisteine

Antiphospholipidic syndrome– Lupus anticoagulant– Anticardiolipine antibodies

CLINICS LAB TESTS

PARACLINICAL EXAMINATIONS

PARACLINICAL EXAMINATION

Ultrasonography

Venogram

ULTRASONOGRAPHY

Lack of complete compresibility of the vein

Visualization of intraluminal thrombus

Distension of the vein compared to the adjacent atery

CT venogram For suspected iliac vein thrombosis

For suspected IVC thrombosis

MRIfor suspected iliofemoral DVT, IVC, SVC.

When venography is contraindicated– Iodine allergy, renal failure

VENOGRAPHY

Obese patients with important edema

Non-invasive evaluation-not clear

TREATMENT COMPLICATIONSDIFFERENTIAL DIAGNOSIS

Acute limb ischemia

Artritis

Limphangitis

Celulitis

Hematoma

Limphedema

Baker chist

Post-trombotic sindrome,

Superficial vein thrombosis

SUPERFICIAL LEG THROMBOSIS

Venous distension

Proeminence of subcutaneous veins

Palpable, indurated cord-like, tender subcutaneous venous segment

TREATMENT COMPLICATIONSTREATMENT

DVT PREVENTION

Enoxaparine 40 mg

PHARMACOLOGICAL

INTERVENTIONAL

SURGICAL

TREATMENT

PHARMACOLOGICALANTICOAGULANT

HEPARINE

FONDAPARINUX

WARFARIN, ACENOCUMAROL

NEW: DABIGATRAN, APIXABAN, RIVAROXABAN

PHARMACOLOGICALHEPARINE

bolus 80U/kg

18 U/kg/hour

APTT 2-3

LMWHSame eficacity as Heparine

1 mg/kg x2/day

FONDAPARINUXSame eficacity as Heparine

7,5 mg

5 mg<50kg

10 mg>100kg

PHARMACOLOGICAL

At least 5 days +

vitamin K antagonist: Warfarin

Until INR >=2 for 24 hours.

WARFARIN

-initial transient hypercoagulable state

WARFARIN

II, VII, IX, X, protC, protS.

X, II t1/2 24-72 hours.

Agravation with Acenocumarol

WARFARIN-duration

Calf DVT – 3 months

Proximal DVT- 6 months

Upper extremity DVT- 3 months

Recurrent episodes- 1 year.

PHARMACOLOGICAL

THROMBOLYSIS:

1. Massive iliofemoral DVT

2. Young patients with phlegmatia alba dolens (limb ischemia)

INTERVENTIONAL

IVC filter:

To block any clots which might embolizeContraindications to anticoagulants

Severe hemorrhagic complications to anticoagulants

Failure to anticoagulant therapy (recurrent DVT, PE)

SURGERY

Massive ileofemoral DVT (phlegmatia cerulea dolens)

+contraindications to thrombolysis

The clot can be removed

Compression stockingsReduces leg edema

Assist the calf muscle pump

From the first day of treatment

Ambulation: day 2 after initiation of anticoagulation therapy

+ compression

TREATMENT COMPLICATIONSCOMPLICATIONS

Post thrombotic syndrome

Pulmonary embolism

COMPLICATIONS

POST THROMBOTIC SYNDROME

POSTTHROMBOTIC SYNDROME

Varicose veins

Abnormal pigmentation

Venous ulcerations

PULMONARY EMBOLISM

In case of a pulmonary embolism, which are the possible complications ?

Ventricular septal defect

Sudden cardiac death

Secondary pulmonary arterial hypertension

Pneumothorax

Renal carcinoma

The pharmacological treatment of non - massive pulmonary embolism can be

made with:

Heparine

Enoxaparine

Streptokinase

Vitamin K agonists (Fitomenadione)

Surgery

Carto + semne EKG

CASE PRESENTATION

ACUTA DYSPNEEA

ANAMNESYS

Male, 67 ani, Sanpaul jud. Cluj

Dyspneea

Dry cough

ANAMNESYS

5 days ago

Dyspneea: brutal, rapid onset during effort

Generalist- Sanpaul

Ambulance-Cluj-Emergency Department

ANTECEDENTS

HTA-2007 max 160/100

Hypercolesterolemia-2007

MEDICATIONS

Prestarium 5 mg 1-0-0 tb/zi.

Simvastatin 20mg 0-0-1 tb/zi.

CLINICAL FINDINGS

T=37,4 ˚C;

pale, mild finger cianosis;

PHYSICAL EXAMINATION

Respiratory: no rales

C-V: tachycardia 120/min, nu murmurs, TA=135/95mmHg.

Hepatomegaly 3cm , +jugular distension.

CLINICAL INTERPRETATION

CARDIAC TAMPONADE?

PULMONARY EMBOLISM?

METABOLIC DYSPNEEA –ACIDOSIS ?

ANEMIA ?

LAB TESTS

I line tests

• CBC• Biochemistry• Coagulation

• ABG• Ddimers

Second line tests

• Thrombophylia tests

LAB TESTS

ESR=14-37

Hb= 14,5 g/dl

L= 14800/mm3

Tr= 131000/mm3

Gli=92mg/dlCol=157mg/dlTgl=56mg/dlAc. Uric=7,2 mg/dlNa=144mEq/lK=3,8mEq/lCa=4,9azot=33mg/dlcreat=1,1mg/dlASAT=15U/lALAT=10U/lLDH=411U/lBilirubina=0,5mg/dlTQ=14,6INR=1,21Troponina I <0,2µg/mlCPK=74U/l

LAB TESTS

I line tests

• ABG• Ddimers

Second line tests

GAZE SANGUINE .

SaO2=87,5%

paO2=51,4

paCO2=29,3

pH=7,495

HCO3=18

LAB TESTS

I line tests

• ABG

• Ddimers

Second line tests

D dimers +2µg/ml (V.N. <0,2µg/ml)

ANALIZE DE LABORATOR

D dimeri +2µg/ml

Troponine I <0,2µg/ml

BNP=74U/l

First line

• EKG• Rx• Ecocardiography

Second line

• Venous ultrasound• Pulmonary scintigraphy• CT angiogram• IRM• Amgiography

First line

Second line

First line

• EKG

• Rx• Ecocardiography

Second line

RX PULMONAR

First line

• EKG• Rx

• Ecocardiography

Second line

• Venous ultrasound• Pulmonary scintigraphy• CT angiogram• IRM• Angiography

ECOCARDIOGRAPHY

IVS - paradoxical movement

TR -PAP=40-45mmHg

First line

Second line

LIMB ULTRASOUND

First line

Second line

• Venous ultrasound• Pulmonary

scintigraphy• CT angiogram• IRM• Angiography

PULMONARY SCINTIGRAPHY

DIAGNOSYS

MODERATE BILATERAL PULMONARY THROMBOEMBOLISM.

DEEP VEIN THROMBOSIS –RIGHT LEG

ARTERIAL HYPERTENSION GRADE 2 (ESC).

TREATMENTOxygen

Clexane 2x80 mg/ziOmeran 20mg/ziCefort 1 grx2/ziCodeine phosphate tbx2/zi

Atacand 16 mg dimineataSimvastatin 20mg/zi

EVOLUTION

CHEST X-ray

PULMONARY EMBOLISMWhat you should know

PULMONARY EMBOLISM

Complication of DVT

Obstruction of one or more branches of the pulmonary artery through an embolus migrating from a deep vein thrombosis

CLINICS

Acute dyspneea with normal pulmonary examination

CLINICS

Dyspneea with normal lungs

severe chest pain

↓ SBP (+/- cardiogenic shock)

cyanosis (respiratory failure)

tachycardia

later: right sided heart failure

CLINICS

Massive pulmonary embolism

Submassive PE

Low risk PE

LAB TESTS

I’st line tests

• ABG• Ddimers

Second line tests

LAB TESTS

I line tests

• ABG• Ddimers

Second line tests

LAB TESTS

I line tests

• ABG

• Ddimers

Second line tests

D-dimers

First line

Second line

First line

Second line

clockwise rotation S1Q3.

Right axis deviation

Ischemic signs Conduction troubles:RBBB

Arrythmias: ST, ExA, ExV, AF, AfT.

First line

Second line

First line

• EKG

• Rx• Ecocardiography

Second line

CHEST X-Ray

Westermark sign

Atelectasis

Small pleural effusion

Elevated diaphragm

Triangular radioopacity with the base towards the pleura

First line

• EKG• Rx

• Ecocardiography

Second line

First line

Second line

First line

Second line

• Venous ultrasound• Pulmonary

scintigraphy• CT angiogram• IRM• Angiography

First line

Second line

First line

Second line

• Venous ultrasound• Pulmonary scintigraphy• CT angiogram• IRM

• Angiography

Myocardial ischemia: RV infarction

Pericarditis: cardiac tamponade

Anemia

Metabolic acidosis

Cardiogenic shock

Aortid dissection

Penumothorax

Cor pulmonale

Musculoskeletal pain

TREATMENT OF PE

Pharmacological

Interventional

Surgical

TREATMENT OF NON-MASSIVE PULMONARY EMBOLISM

PharmacologicalHEPARINE

FONDAPARINUX

PharmacologicalHEPARINE: 80 U/kg or 5000 bolus

– infusion: 18 U/kg/h or 1300 U/kg– APTT– Renal impairment CrCl<20-30ml/min

LMWH no monitoring

FONDAPARINUX anti-X a

aPTT=activated partial thromboplastin time, with therapeutic range-60-80

seconds.

FONDAPARINUX=anticoagulant that specifically inhibits activated factor X.

WARFARIN

Vit K antagonist

After 5 days of Heparine/LMWH or Fondaparinux

2 consecutive days of INR 2-3

INR-2-3.

DURATION OF TREATMENT

Calf DVT – 3 months

Proximal DVT- 6 months

Upper extremity DVT- 3 months

Pulmonary embolism- 6 months

Pulmonary embolism+cancer -lifelong

Recurrent PE – lifelongPulmonary embolism + AT III deficiency/Leiden mutation, prot C, prot S deficiency – life-long.

TREATMENT OF MASSIVE PULMONARY EMBOLISM

THROMBOLYSIS

Streptokinase

Urokinase

Alteplase

Reteplase

Tenecteplase

Heparine+Thrombolysis+Volume 500-1000ml

THROMBOLYSIS

Streptokinase 1,5 mil U/2h

Urokinase 3 milU/2 h

Alteplase 100mg/2h

Reteplase 10U+10U (30 min)

Tenecteplase 30 mg bolus50mg

Heparine+Thrombolysis+Volume 500-1000ml

14 days

INTERVENTIONAL

IVC FILTERS:

1. CI to anticoagulants

2. Massive PE who survived –recurrent may be fatal.

3. Recurrent venous thromboembolism under anticoagulants

SURGICAL

Pulmonary endarterectomy

COMPLICATIONS

Sudden cardiac death

Atrial/Ventricular arrythmias

Secondary PAH

Cor pulmonale

Severe hypoxemia

Right-to-left intracardiac shunt

Lung infarction

DEFINITION ETIOLOGY

Factor II

Slide ajutator

Deep vein thrombosis and Pulmonary embolism 2014

Health & Medicine

DEEP VEIN THROMBOSIS AND PULMONARY EMBOLISM: DIAGNOSIS · PDF fileDVT (Deep Vein Thrombosis) and PE (Pulmonary Embolism) Policy V4 - 1 - December 2015 DEEP VEIN THROMBOSIS AND PULMONARY

Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

IBD e disturbi della coagulazione-Spiezia · • Deep venous thrombosis • Pulmonary embolism • Portal vein thrombosis, Budd Chiari syndrome • Cerebral venous sinus thrombosis

Guidance for the treatment of deep vein thrombosis …williams.medicine.wisc.edu/PE_DVT_treatment_2016.pdfGuidance for the treatment of deep vein thrombosis and pulmonary embolism

Deep Vein Thrombosis and Pulmonary Embolism · 3 About Deep Vein Thrombosis Venous thrombosis happens when a blood clot forms in one of more veins. When the blood clots stick to the

Guidelines for the Diagnosis, Treatment and Prevention of Pulmonary Embolism and Deep Vein Thrombosis (JSC 2009) (1)

Deep Vein thrombosis and Pulmonary embolism

VTE Guide for Executive LeadershipDeep Vein Thrombosis and Pulmonary Embolism, 2008. Definitions of Deep Vein Thrombosis, Pulmonary Embolism, and Venous Thromboembolism. 2 “Deep

ANEURYSM . THROMBOSIS EMBOLISM & DEEP VEIN THROMBOSIS

Thrombosis, Embolism, Infarction

Deep Vein Thrombosis of the Arms...Deep Vein Thrombosis 130 third of patients with deep arm vein thrombosis will have primary thrombosis, i.e. idiopathic and effort-related thrombosis

Deep Vein Thrombosis Ultrasound Pocket Card...Deep Vein Thrombosis Scanning Sites Common Femoral Vein Great Saphenous Vein (Superﬁcial) Femoral Vein Popliteal Vein Popliteal Vein

Vascular Disorders: Deep Vein Thrombosis, Pulmonary Embolism, Peripheral Vascular Disease Brunner ch 31, pp 848-866, 874-884

Deep Vein Thrombosis and Pulmonary Embolism Information for

Thrombosis & embolism

Thrombosis, Thrombophlebitis and embolism · Thrombosis, Thrombophlebitis and embolism PST 515 –Physiotherapy in disorders of blood and lymph vessels . Thrombosis •Thrombosis

Cancer-Associated Venous Thromboembolic Disease · Acute Deep Vein Thrombosis (DVT-1) Acute Pulmonary Embolism (PE-1) Heparin-Induced Thrombocytopenia (HIT-1) Splanchnic Vein Thrombosis

Deep Vein Thrombosis and Pulmonary Embolism: Diagnosis and ...€¦ · Pascal Bastien, MD FRCPC . On behalf of Thrombosis Canada . Pascal Bastien has received fees/honoraria from

Thrombosis &Embolism

Deep Vein Thrombosis and Pulmonary Embolism, by Prof. Minnu M. Panditrao