DVT & PE

Deep vein thrombosis &

Pulmonary embolism

Deep vein thrombosis A form of thrombophlebitis Incidence- ~1 per 1000 persons per year Commonly affects leg veins (L>R)-

popliteal, femoral, pelvic Virchow’s triad- Decreased blood flow- stasis Damage to vessel wall Hypercoagulability Complication- Pulmonary embolism Post-phlebitic syndrome

DVT- risk factors Recent surgery Hospitalization Advanced age Obesity Immobilization Thrombophilia- AT-

III/protein C or S deficiency

Pregnancy Estrogen containing

OCP Tobacco use Prolonged economy

class air travel Cancer Infection

DVT-clinical presentation Underlying risk factors Symptoms Pain, swelling, redness of leg Superficial vein dilatation Signs Edema, tender veins Homan’s sign- calf pain on dorsiflexion of foot Acute DVT may cause impaired circulation

cold extremity, absent pulse, even gangrene

DVT- diagnosis

D-dimer level- a FDPDuplex ultrasonography, with

compressionCT venography (iliocaval DVT)

DVT- management Mostly out-patient, using LMWH Hospitalization recommended- B/L DVT Extensive proximal DVT CRI CHF Cancer Recent immobility Low body weight

Anticoagulation Low molecular weight heparin (LMWH) Fondaparinux Unfractionated heparin- requires

hospitalization & monitoring (aPTT)Dose- 80 U/kg bolus18 U/kg/hr infusionmonitor aPTT

Long-term Warfarin- at least 3 monthsDose- 5 mg OD x 3 daysmonitor PT Life-long for life-threatening/recurrent DVT Monitor PT/INR- 2-3 times normal

Other Rx options Thrombolysis for extensive proximal

clot, increases risk of bleeding

Intermittent pneumatic compression- (IPC) if heparin CI or post-op.

IVC filter- reduces PE, used in patients with ICH, potentially prothrombotic

DVT- prevention LMWH/UFH in hospitalised patients with risk

factors for DVT LMWH post-op. IPC after knee/hip surgery Elastic compression stockings during long-

haul flights Heparin/LMWH/Warfarin in at risk pregnancy Early mobil ization

Post-phlebitic syndrome Occurs in ~15% patients with DVT Consequences- Edema Pain Cramps Venous claudication Skin pigmentation Dermatitis Ulceration

Pulmonary embolism Commonly embolism from DVT

Risk more with proximal DVT

Risk factors- as for DVT

Clot obstructs pulmonary arterial circulation & strains right ventricle

PE- diagnosis Risk factors ± DVT Symptoms- Mostly silent ~15% of sudden deaths attributable to PE May cause sudden SOB, pleuritic chest pain,

hemoptysis Signs Tachypnea, cyanosis, pleural rub, low-grade fever RV strain- loud P2, LPSH, raised JVP

PE- diagnosis Investigations- CBC, PT/aPTT, LFT, RFT- for R/F CxR- mainly to rule out other pathology ECG- tachycardia, RV strain, R/O MI ECHO- RV dysfunction, R/O MI D-dimer ± US- for DVT CT pulmonary angiography- for PE Dx V-Q scan- contrast allergy/CI

PE- treatment Anticoagulation LMWH/Fondaparinux/Heparin Warfarin x minimum 3 months, lifelong if recurrent

Thrombolysis PE with hemodynamic instability PE with RV dysfunction on ECHO Surgical thrombectomy

H.I.T Heparin induced thrombocytopenia An immune reaction to Heparin/LMWH Paradoxical increase in arterial/venous

thrombosis, with thrombocytopenia Can occur upto 100 days after exposure Rx- Stop Heparin/LMWH Anticoagulation with direct thrombin inhibitors (monitor aPTT)-

lepirudin, argatroban, bivaluridin- until platelet count stabilizes

Long-term Warfarin