deep venous thrombosis & pulmonary embolism

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  • Pulmonary Embolism & DVT

  • Introduction

    PathophysiologyRisk FactorsSymptomsLab FindingsRadiology FindingsTreatmentPrevention

  • Pathophysiology

    Dislodgement of a blood clot:

    Lower Extremities: 65% to 90%Pelvic venous systemRenal venous systemUpper ExtremityRight Heart

  • Risk Factors for PE and DVT

    ImmobilizationSurgery within the last 3 monthsStrokeHistory of venous thromboembolismMalignancyPreexisting respiratory diseaseChronic Heart DiseaseAge >60Surgery requiring >30mins of anesthesia

    Recent travel (past 2weeks, >4 hours)Varicose veinsSuperficial vein thrombosisCentral VV catheter/port/pacemaker

    Additional RF in Women:

    Obesity BMI >/=29Heavy smoking (>25cigs/day)HypertensionPregnancy

  • Wells Criteria

    >6: High Risk

    2 to 6:Moderate Risk

    2 or less:Low

    Adapted with permission from Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, et al. Derivation of a simple

    clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED d-dimer.

    Thromb Haemost 2000;83:416-20.

    Clinical Signs and Symptoms of DVT?(Calf tenderness, swelling >3cm, errythema, pitting edema affected leg only)+3PE Is #1 Diagnosis, or Equally Likely+3Heart Rate > 100+1.5Immobilization at least 3 days, or Surgery in the Previous 4 weeks+1.5Previous, objectively diagnosed PE or DVT?+1.5Hemoptysis+1Malignancy w/ Rx within 6 mo, or palliative?+1

  • P.E. and Malignancy

    A Presenting sign in: Pancreatic cancerProstate cancerLate sign in:Breast cancerLung cancerUterine cancerBrain cancer

  • Symptoms of P.E.

    DyspneaPleuritic painCoughHemoptysis (blood tinged/streaked/ pure blood)

  • Signs of P.E.

    TachypneaRalesTachycardiaHypoxiaS4Accentuated pulmonic component of S2Fever: T
  • Signs in Massive P.E.

    Massive PE: hemodynamic instability with SBP /=40mmHgSigns as before PLUS:Acute right heart failureElevated J.V.P.Right-sided S3Parasternal lift

  • P.E. & Leg Symptoms

    Most patients with P.E. do not have leg symptoms at time of diagnosisPatients with leg symptoms may have asymptomatic P.E.

  • Lab & Radiologic Findings in P.E.

    ABGBNPCardiac Enzymes: TroponinD-dimerEKGCXRUltrasoundV/Q ScanAngiography

  • Lab Findings in P.E.(ABG)

    ABG:HypoxemiaHypocapnia (low CO2)Respiratory AlkalosisMassive PE: hypercapnia, mix resp and metabolic acidosis (inc lactic acid)Patients with RA pulse ox readings
  • Lab Findings in P.E. (BNP)

    BNP (beta natruretic peptide)Insensitive testPatients with PE have higher levels than pts without, but not ALL patients with PE have high BNPGood prognostic value measure: if BNP >90 associated with adverse clinical outcomes (death, CPR, mechanical vent, pressure support, thrombolysis, embolectomy)

  • Lab Findings in P.E. (Troponin)

    TroponinHigh in 30-50% of pts with mod to large PEPrognostic value if combined pro-NT BNPTrop I >0.07 + NT-proBNP >600 = high 40 day mortality

  • Lab Findings in P.E. (D-dimer)

    D-dimer:Degredation product of fibrin>500 is abnormalSensitivity: High, 95% of PE pts will be positiveSpecificity: LowNegative Predictive Value: Excellent

  • S1Q3T3!!!

  • RAD

    Right Atrial Enlargement

  • Lab Findings in P.E. (contd)

    EKG2 Most Common finding on EKG:Nonspecific ST-segment and T-wave changesSinus TachycardiaHistorical abnormality suggestive of PES1Q3T3Right ventricular strainNew incomplete RBBB

  • Radiologic Findings in P.E.

  • GOLD STANDARD IN DIAGNOSING PULMONARY EMBOLISM?

    PULMONARY ANGIOGRAM

  • Radiology Findings in P.E. (contd)

    CXR:NormalAtelectasis and/or pulmonary parenchymal abnormalityPleural EffusionCardiomegally

  • Whats This???

    Hamptons Hump

  • How About This???

    Westermark's Sign: an abrupt tapering of a vessel caused by pulmonary thromboembolic obstruction.

    This CXR shows enlargement of the left hilum accompanied by left lung hyperlucency, indicating oligemia (Westermark's sign).

  • Radiology Findings in P.E. (contd)

    V/Q Scan:

    Results: High, Intermediate, Low ProbabilityBest if combined with Clinical Probability (PIOPED study):High Clinical Prob + High Prob VQ= 95% likelihood of having a P.E.Low Clinical Prob + Low Prob VQ= 4% likelihood of having a P.E.

  • Radiology Findings in P.E. (contd)

    Lower Extremity Ultrasounds

    If DVT found then treatment is same if patient has a P.E.Disadvantage: If negative, patients with PE may be missedIf false positive (3%), unnecessary intervention

  • Radiology Findings in P.E. (contd)

    CT Pulmonary Angiography (CT-PA)

    Widely usedInstitution dependentSensitivity (83%)Specificity (96%): if negative, very low likelihood that pt has P.E.

  • Radiology Findings in P.E. (contd)

    Pulmonary Angiogram

    Gold StandardNot easily accessible Radiologist dependent

  • Radiology Findings in P.E. (contd)

    Echocardiogram

    Increased Right Ventricle SizeDecreased Right Ventricular FunctionTricuspid Regurgitation

    Rarely:

    RV thrombusRegional wall motion abnormalities that spare the right ventricle apex (McConnells Sign)

  • Hypercoagulability Work Up

    No consensus on who to testIncreased likelihood if:Age
  • Hypercoagulability Work Up

    Protein C/S deficiencyFactor V leiden deficiencyAntiThrombin III deficiencyProthrombin 20210 mutationAntiphospholipid antibodyHigh Homocysteine

  • Most Common Cause of Congenital Hypercoagulablity

    Protein C resistance d/t Factor V leiden mutation

  • Treatment of P.E.

    Respiratory Support: Oxygen, intubationHemodynamic Support: IVF, vasopressorsAnticoagulationThrombolysisIVC Filter

  • Anticoagulation

    Start during resuscitation phase itselfIf suspicion high, start emperic anticoagulation Evaluate patient for absolute contraindication (i.e.: active bleeding)

  • Anticoagulation (contd)

    HEPARIN:Lovenox: if hemodynamically stable, no renal function1mg/kg BID OR 1.5mg/kg QDayHeparin gtt: if hypotension, renal failure80units/kg bolus then 18units/kg infusionGoal PTT1.5 to 2.5 times the upper limit of normalCOUMADIN:Start once acute anticoagulation achievedStart with 5mg PO qday OR 10mg PO q dayIf start with 10mg then achieve therapeutic INR 1.4 days soonerComplications and morbidity no different in 5mg or 10mg start Goal INR 2 to 3

  • Duration of Anticoagulation for DVT or PE*

    *From American College of Chest Physicians

    EventDurationStrength of RecommendationFirst Time event of Reversible cause (surgery/trauma)At least 3 mosAFirst episode of idiopathic VTEAt least 6 mosARecurrent idiopathic VTE or continuing risk factor (e.g., thrombophilia, cancer)At least 12 mosBSymptomatic isolated calf-vein thrombosis6 to 12 weeksA

  • Thrombolysis

    Considered once P.E. diagnosedIf chosen, hold anticoagulation during thrombolysis infusion, then resumedAssociated with higher incidence of major hemorrhage Indications: persistent hypotension, severe hypoxemia, large perfusion defecs, right ventricular dysfunction, free floating right ventricular thrombus, paten foramen ovaleActivase or streptokinase

  • IVC Filter

    Indication: Absolute contraindication to anticoagulation (i.e. active bleeding)Recurrent PE during adequate anticoagulationComplication of anticoagulation (severe bleeding)Also: Pts with poor cardiopulmonary reserveRecurrent P.E. will be fatalPatients who have had embolectomyProphylaxis against P.E. in select patients (malignancy)

  • Embolectomy

    Surgical or catheterIndication:Those who present severe enough to warrant thrombolysis In those where thrombolysis is contraindicated or fails

  • Questions?

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