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

DVT ?

Superficial femoral vein

Profound femoral vein

Superficial femoral vein

Profound femoral vein

NO

DVT

NO

DVT

NO

DVT











ETIOLOGY

Virchow’s triad

-1) blood stasis

- 2)parietal venous lesion (endothelial damage)

-3) hypercoagulability











MORPHOPATHOLOGY

MORPHOPATHOLOGY

VENOUS vs ARTERIAL











CLINICS

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

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

MRI

CT

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

LMWH

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

.

.

.

.

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


EKG

EKG

EKG

EKG


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

RV=31

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

EKG

EKG

CHEST X-ray

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

D-dimers












First line


Second line



First line


Second line


EKG

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

COPD

Penumothorax

Cor pulmonale

Musculoskeletal pain











TREATMENT OF PE

Pharmacological

Interventional

Surgical

TREATMENT OF NON-MASSIVE PULMONARY EMBOLISM

PharmacologicalHEPARINE

LMWH

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.

LMWH

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

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

Shoc

PEA

Atrial/Ventricular arrythmias

Secondary PAH

Cor pulmonale

Severe hypoxemia

Right-to-left intracardiac shunt

Lung infarction

NO

DEFINITION ETIOLOGY

Factor II

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Deep vein thrombosis and Pulmonary embolism 2014