31
PE and DVT PE and DVT

PE and DVT

  • Upload
    sanam

  • View
    40

  • Download
    0

Embed Size (px)

DESCRIPTION

PE and DVT. Pathogenesis of VT. Virchow’s triad: Damage to vessel wall Venous stasis Hypercoagulability . Source. Most PE’s originate from thrombi in the deep venous system of the legs, although they may also originate in the pelvic, renal or upper extremity veins. - PowerPoint PPT Presentation

Citation preview

Page 1: PE and DVT

PE and DVTPE and DVT

Page 2: PE and DVT

Pathogenesis of VTPathogenesis of VT

Virchow’s triad:Virchow’s triad:– Damage to vessel wallDamage to vessel wall– Venous stasisVenous stasis– Hypercoagulability Hypercoagulability

Page 3: PE and DVT

SourceSourceMost PE’s originate from thrombi in the deep Most PE’s originate from thrombi in the deep venous system of the legs, although they may venous system of the legs, although they may also originate in the pelvic, renal or upper also originate in the pelvic, renal or upper extremity veins. extremity veins. HOWEVER, less than 30% of pts will have HOWEVER, less than 30% of pts will have symptoms in their legs at the time of diagnosis of symptoms in their legs at the time of diagnosis of PEPE20% of calf vein thrombi propagate above the 20% of calf vein thrombi propagate above the popliteal fossa. popliteal fossa. 20% of lower extremity venous emboli begin in 20% of lower extremity venous emboli begin in the proximal veins without prior calf involvement. the proximal veins without prior calf involvement.

Page 4: PE and DVT

Acquired Risk FactorsAcquired Risk FactorsAgeAgePrevious thrombosisPrevious thrombosisImmobilizationImmobilizationMajor surgery – especially OrthoMajor surgery – especially OrthoEstrogen – OCP, HRT, SERMsEstrogen – OCP, HRT, SERMsAntiphospholipid Ab syndromeAntiphospholipid Ab syndromeMalignancyMalignancyNephrotic syndromeNephrotic syndromeInflammatory bowel diseaseInflammatory bowel diseaseMyeloproliferative d/o – esp p. vera and ETMyeloproliferative d/o – esp p. vera and ETPNHPNHLong distance air travelLong distance air travelHITHIT

Page 5: PE and DVT

Inherited Risk FactorsInherited Risk Factors

Factor V Leiden mutationFactor V Leiden mutationG20210A prothrombin gene mutationG20210A prothrombin gene mutationAntithrombin deficiencyAntithrombin deficiencyProtein C or S deficiencyProtein C or S deficiencyDysfibrinogenemiaDysfibrinogenemiaHyperhomocysteinemiaHyperhomocysteinemia

Page 6: PE and DVT

PresentationPresentationDyspneaDyspneaPleuritic chest painPleuritic chest painCough +/- hemoptysisCough +/- hemoptysisOn exam may have On exam may have

TachypneaTachypneaTachycardiaTachycardiaS4S4Loud P2Loud P2May have fever – rarely >102May have fever – rarely >102In massive PE can have hypotension and shockIn massive PE can have hypotension and shock

Look at legs for swelling and Homan’s sign – but Look at legs for swelling and Homan’s sign – but only helpful if positive. only helpful if positive.

Page 7: PE and DVT

Homan’s SignHoman’s Sign

Passive dorsiflexion of the foot with the Passive dorsiflexion of the foot with the knee straight may give pain in the calf and knee straight may give pain in the calf and back of the knee when there is a deep back of the knee when there is a deep venous thrombosis. venous thrombosis. Some concern that vigorous dorsiflexion of Some concern that vigorous dorsiflexion of the foot can expel clot from the veins and the foot can expel clot from the veins and so this test may have its dangers. so this test may have its dangers. The sign is not specific for DVTThe sign is not specific for DVT

Page 8: PE and DVT

DDX swollen calfDDX swollen calf

DVTDVTBakers CystBakers CystCellulitisCellulitisGout – if really bad it can sometimes look Gout – if really bad it can sometimes look like a cellulitislike a cellulitisIf bilateral think about CHF, Nephrotic If bilateral think about CHF, Nephrotic syndrome, liver failure, venous syndrome, liver failure, venous insufficiency, pregnancy or pelvic mass, insufficiency, pregnancy or pelvic mass, vasodilators esp nifedipinevasodilators esp nifedipine

Page 9: PE and DVT

ABGABGUsually shows hypoxia, hypocapnia, respiratory alkalosisUsually shows hypoxia, hypocapnia, respiratory alkalosisA-a gradient:A-a gradient:

Normal 7-14 depending on ageNormal 7-14 depending on ageIncreases with age, FiO2 and supine postureIncreases with age, FiO2 and supine postureEstimate of normal for age: Estimate of normal for age:

– Age/4 +4Age/4 +4A-a gradient = (FiO2 x713 – pCO2/0.8) – PaO2A-a gradient = (FiO2 x713 – pCO2/0.8) – PaO2

If A-a gradient normal, PaO2 <80, Pa CO2 >45 then If A-a gradient normal, PaO2 <80, Pa CO2 >45 then hypoventilation accounts for hypoxiahypoventilation accounts for hypoxiaIncreased A-a gradient occurs in V/Q mismatch, Increased A-a gradient occurs in V/Q mismatch, shunting and any kind of barrier to diffusion (e.g. shunting and any kind of barrier to diffusion (e.g. pulmonary edema)pulmonary edema)BUT can be normal and still have PE!BUT can be normal and still have PE!

Page 10: PE and DVT

LabsLabs

Troponin, LDH, AST and BNP may all be Troponin, LDH, AST and BNP may all be elevatedelevatedCheck baseline CBC, PT/PTT/INR, CrCheck baseline CBC, PT/PTT/INR, CrD-dimer D-dimer

Normal D-dimer excludes PE, but positive D-Dimer Normal D-dimer excludes PE, but positive D-Dimer is not helpful (as it can be positive in many is not helpful (as it can be positive in many conditions including sepsis, immobility, post Sx and conditions including sepsis, immobility, post Sx and CAP)CAP)

Page 11: PE and DVT
Page 12: PE and DVT
Page 13: PE and DVT

EKGEKG

May have non specific ST and T wave changesMay have non specific ST and T wave changes““Typical” SI, QIII, TIII - rare. Typical” SI, QIII, TIII - rare. Sinus tachycardiaSinus tachycardiaT wave inversions in right to mid chest leadsT wave inversions in right to mid chest leadsPoor R wave progression (acute RV dilation)Poor R wave progression (acute RV dilation)P pulmonaleP pulmonaleRV conduction delaysRV conduction delaysRight axis shiftRight axis shift

Page 14: PE and DVT

CXRCXR

May have area of atelectasisMay have area of atelectasisMay have wedge shaped infarct May have wedge shaped infarct peripherallyperipherallyPleural effusion occurs in about 40%Pleural effusion occurs in about 40%

Page 15: PE and DVT
Page 16: PE and DVT

V/Q scanningV/Q scanning

Look for evidence of ventilation perfusion Look for evidence of ventilation perfusion mismatchmismatchCan only really be done if pt has normal CXRCan only really be done if pt has normal CXRNormal scan virtually excludes PE even if Normal scan virtually excludes PE even if pretest clinical probability was felt to be high. pretest clinical probability was felt to be high. If a patient with intermediate clinical probability If a patient with intermediate clinical probability of PE has an intermediate scan then need of PE has an intermediate scan then need further testingfurther testing

Page 17: PE and DVT

A 60-year-old man with asthma is evaluated in the emergency A 60-year-old man with asthma is evaluated in the emergency department because of the acute onset of chest pain while lifting a department because of the acute onset of chest pain while lifting a heavy object. The pain is sharp and accentuated by deep breathing heavy object. The pain is sharp and accentuated by deep breathing and by movement of the upper extremities. It is located over the left and by movement of the upper extremities. It is located over the left precordium. precordium.

The physical examination and chest x-ray are normal. A ventilation-The physical examination and chest x-ray are normal. A ventilation-perfusion lung scan shows matched areas of perfusion and perfusion lung scan shows matched areas of perfusion and ventilation. ventilation.

Which one of the following is the correct interpretation of the Which one of the following is the correct interpretation of the ventilation-perfusion lung scan?ventilation-perfusion lung scan?( A ) Normal( A ) Normal( B ) Low probability( B ) Low probability( C ) Indeterminate( C ) Indeterminate( D ) High probability( D ) High probability

Page 18: PE and DVT

Correct Answer = Correct Answer = AA

The lung scan is normal, with matched perfusion and The lung scan is normal, with matched perfusion and ventilation. This lung scan rules out a pulmonary ventilation. This lung scan rules out a pulmonary embolism, and another source for the chest pain should embolism, and another source for the chest pain should be sought. Often asthma does complicate the be sought. Often asthma does complicate the interpretation of the lung scan, but the problem relates to interpretation of the lung scan, but the problem relates to matched defects in which the airway obstruction matched defects in which the airway obstruction decreases the ventilation to an area of the lung. The decreases the ventilation to an area of the lung. The consequent hypoxia in that area leads to reduction in consequent hypoxia in that area leads to reduction in blood flow in the same area. These areas are rarely blood flow in the same area. These areas are rarely segmental. segmental.

Page 19: PE and DVT

Doppler US of lower extremitiesDoppler US of lower extremities

If high clinical suspicion should be If high clinical suspicion should be repeated 7-10 days after initial scan as repeated 7-10 days after initial scan as below knee DVT can propagatebelow knee DVT can propagateAlso remember that some pt develop Also remember that some pt develop DVT’s elsewhere – so you may not find a DVT’s elsewhere – so you may not find a DVT in their legs if the source was their DVT in their legs if the source was their arm!arm!

Page 20: PE and DVT

Spiral CT/CT angiogramSpiral CT/CT angiogram

Used if CXR not normalUsed if CXR not normalPicks up large central emboli but is less Picks up large central emboli but is less sensitive for the smaller peripheral emboli. sensitive for the smaller peripheral emboli. True pulmonary angiography rarely used True pulmonary angiography rarely used now, though can do direct thrombolysis in now, though can do direct thrombolysis in massive PE.massive PE.

Page 21: PE and DVT
Page 22: PE and DVT

EchoEcho

More than 80% of pts with PE will have More than 80% of pts with PE will have abnormalities of RV size or function, or TR.abnormalities of RV size or function, or TR.McConnells sign – regional wall motion McConnells sign – regional wall motion abnormalities that spare the R ventricular apex abnormalities that spare the R ventricular apex are very suggestive of PEare very suggestive of PEBUT echo is only really used for Dx of massive BUT echo is only really used for Dx of massive lifethreatening PE’s when rapid diagnosis is lifethreatening PE’s when rapid diagnosis is needed to determine whether thrombolysis needed to determine whether thrombolysis should be given.should be given.

Page 23: PE and DVT

TreatmentTreatment

Identify any contraindications to Identify any contraindications to anticoagulations – if yes then IVC filteranticoagulations – if yes then IVC filterInquire about h/o HITInquire about h/o HIT

If yes, then use direct thrombin inhibitorIf yes, then use direct thrombin inhibitor

Assess need for hospitalizationAssess need for hospitalizationExtensive iliofemoral DVT with circ compromiseExtensive iliofemoral DVT with circ compromiseIncreased risk of bleedingIncreased risk of bleedingLimited cardioresp reserveLimited cardioresp reservePoor compliancePoor complianceCI to LMW heparinCI to LMW heparin

Page 24: PE and DVT

TreatmentTreatment

Administer LMW heparin or unfractionated Administer LMW heparin or unfractionated heparinheparinGoal 1.5-2.5 x PTT in first 24 hoursGoal 1.5-2.5 x PTT in first 24 hoursCheck platelet count on day 3-5Check platelet count on day 3-5Treat at least five days and until patient’s Treat at least five days and until patient’s INR is >2 on coumadin for two INR is >2 on coumadin for two consecutive daysconsecutive daysStart coumadin on day 1Start coumadin on day 1

Page 25: PE and DVT

Treatment DurationTreatment Duration

3-6 months in most patients3-6 months in most patientsIndefinite treatment:Indefinite treatment:– >1 spontaneous event>1 spontaneous event– One spontaneous life threatening eventOne spontaneous life threatening event– Antiphospholipid syndromeAntiphospholipid syndrome– Antithrombin deficiencyAntithrombin deficiency– >1 genetic allelic abnormality>1 genetic allelic abnormality

– Homozygote for Factor V Leiden or prothrombin gene mutationHomozygote for Factor V Leiden or prothrombin gene mutation– Heterozygote for bothHeterozygote for both

– Protein C/S deficiencyProtein C/S deficiency– Continuing RF especially active advanced CAContinuing RF especially active advanced CA

Page 26: PE and DVT

Contraindications to Contraindications to AnticoagulationAnticoagulation

AbsoluteAbsolute– Active bleedingActive bleeding– Severe bleeding diathesisSevere bleeding diathesis– Platelet count <20Platelet count <20– Neurosurgery, ocular surgery or intracranial Neurosurgery, ocular surgery or intracranial

bleeding within the past 10 daysbleeding within the past 10 days

Page 27: PE and DVT

Contraindications to Contraindications to AnticoagulationAnticoagulation

RelativeRelative– Mild/moderate bleeding diathesis or Mild/moderate bleeding diathesis or

thrombocytopeniathrombocytopenia– Brain metsBrain mets– Major abdominal surgery within 2 daysMajor abdominal surgery within 2 days– GI or GU bleeding within 14 daysGI or GU bleeding within 14 days– EndocarditisEndocarditis– Severe HTN (SBP >200, DBP > 120)Severe HTN (SBP >200, DBP > 120)

Page 28: PE and DVT

Inferior Vena Cava FilterInferior Vena Cava Filter

Reduce risk of PE but carry increased risk Reduce risk of PE but carry increased risk of DVTof DVTUse in pts with DVT who cannot take Use in pts with DVT who cannot take anticoagulation e.g. due to bleeding riskanticoagulation e.g. due to bleeding riskAlso used with or without anticoagulation Also used with or without anticoagulation in patients with high risk of death should in patients with high risk of death should further PE occur. further PE occur.

Page 29: PE and DVT

Hypercoagulation WorkupHypercoagulation Workup

Test all patients for unprovoked VT for Test all patients for unprovoked VT for antiphospholipid ab syndrome and antiphospholipid ab syndrome and hyperhomocysteinemiahyperhomocysteinemia

Page 30: PE and DVT

Hypercoagulation WorkupHypercoagulation Workup

Test for Factor V Leiden, prothrombin gene Test for Factor V Leiden, prothrombin gene mutation and deficiencies of antithrombin, mutation and deficiencies of antithrombin, protein C/S in the following patients:protein C/S in the following patients:

Family h/o VTFamily h/o VTVT before the age of 50VT before the age of 50Recurrent VTRecurrent VTThrombosis in an unusual site (mesenteric, renal, cerebral, Thrombosis in an unusual site (mesenteric, renal, cerebral, hepatic)hepatic)Heparin resistance (antithrombin deficiency)Heparin resistance (antithrombin deficiency)Warfarin induced skin necrosis (protein C/S def)Warfarin induced skin necrosis (protein C/S def)Neonatal purpura fulminansNeonatal purpura fulminans

Page 31: PE and DVT

Hypercoagulation WorkupHypercoagulation Workup

Wait to check for deficiency in Wait to check for deficiency in antithrombin, protein C or S until 2 weeks antithrombin, protein C or S until 2 weeks after anticoagulation rx is completedafter anticoagulation rx is completed