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  • Thrombosis, Thrombophlebitis and embolism

    PST 515 – Physiotherapy in disorders of blood and lymph vessels

  • Thrombosis

    • Thrombosis is the formation, from constituents of blood, of an abnormal mass within the vascular system of a living animal. It is the formation of solid mass in circulation from the constituents of flowing blood with intact cardiovascular tree during life

    • When it occurs in the deep veins, it is referred to as deep vein thrombosis (DVT)

    • Thrombus is composed predominantly of fibrin and red cells

    • It is a critical vascular disorder associated with morbidity and mortality.

    PST 515 - Physiotherapy in disorders of blood and lymph vessels

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  • PST 515 - Physiotherapy in disorders of blood and lymph vessels

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    When a clot breaks away from the wall of a vein and travels proximally, it is called an embolus.

  • Mechanism/pathophysiology

    • The integrity of a closed, low or high pressure circulatory system is maintained by haemostasis

    • Heamostasis is the process of maintaining blood in a fluid, clot-free state in normal vasculature.

    • Disruption in haemostasis leads to thrombosis

    • Vessel trauma stimulates the clotting cascade. Platelets aggregate at the site particularly when venous stasis is present. Platelets and fibrin form the initial clot

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  • Mechanism/pathophysiology

    • The thrombus propagates in the direction of the blood flow.

    • Inflammation is triggered, causing tenderness, swelling, and erythema.

    • Pieces of thrombus may break loose and travel through circulation- emboli.

    • Fibroblasts eventually invade the thrombus, scarring vein wall and destroying valves.

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  • Aetiology

    Venous Stasis

    Endothelial damage

    Hypercoagulable state

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    The formation of thrombosis is described by the Virchow’s Triad

  • Venous Stasis

    • Venous stasis can result from • Prolonged bed rest • Leg cast • Paralysis of a limb • Spinal cord injury • Extended travel in a vehicle

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  • Hypercoagulable state

    • Hypercoagulable state could result from: • Surgery and trauma

    • Malignancy

    • Increased oestrogen

    • Coagulation disorders (nephrotic disorders, anti-phospholipid antibodies)

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  • Endothelial damage

    Endothelial damage occurs when there is injury to the vascular endothelium

    • Trauma

    • Surgery

    • Invasive procedure

    • Iatrogenic cause – central venous catheters. (subclavian, internal jugular veins)

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  • Deep Vein Thrombosis

    • Lower extremity venous thrombosis can occur in the superficial vein system (greater or small saphenous veins)or the deep vein system (popliteal, femoral, or iliac veins)

    • It typically starts in the lower extremities and progress proximally to involve the popliteal, femoral and iliac system

    • Deep vein Thrombosis is more dangerous than superficial thrombophlebitis

    • A lower extremity DVT is a common complication after musculoskeletal injury or surgery, prolonged immobilization, or bed rest and is attributed to venous stasis, injury to and inflammation of the walls of a vein, or a hypercoagulable state of the blood

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  • Signs and symptoms

    • In the early stages of DVT, most cases are asymptomatic with only 25% to 50% of cases having clinical manifestations

    • Dull aching or severe pain, swelling, or changes in skin temperature and colour, specifically heat and redness

    • Oedema may be present

    • Clot in the calf be felt/detected with the Homan’s sign. (Homan’s sign sensitivity is poor)

    • Deep vein thrombosis often cannot be seen or felt by the individual.

    • Swelling of the leg or fever may alert a person to the presence of a DVT, especially if risk factors for DVT exist

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  • Thrombophlebitis

    • Thrombophlebitis is a common inflammatory thrombotic process that may occur spontaneously or as a complication of medical or surgical interventions

    • It is characterized by acute inflammation with partial or complete occlusion of a superficial or deep vein.

    • It is inflammation due to a blood clot in a vein

    • It usually occurs in the veins of the legs

    • Superficial thrombophlebitis occurs in visible veins under the skin

    • The area of inflammation is usually reddened, tender, warm to touch and sometimes painful.

    • Patients with superficial thrombophlebitis often describe a history of a gradual onset of localised tenderness, followed by the appearance of an area of erythema along the path of a superficial vein.

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  • PST 515 - Physiotherapy in disorders of blood and lymph vessels

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    Superficial Thrombophlebitis

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  • Risk factors for thrombophlebitis and deep vein thrombosis • Postoperative or post-fracture immobilization

    • Prolonged bed rest

    • Trauma to venous vessels

    • Limb paralysis

    • Active malignancy (within past 6 months)

    • History of deep vein thrombosis or pulmonary embolism

    • Advanced age

    • Obesity

    • Sedentary lifestyle or extended episode of sitting during long-distance travel

    • Congestive heart failure

    • Use of oral contraceptives

    • Pregnancy

  • Embolism

    • A process of partial or complete obstruction of some part of the cardiovascular system by any mass carried in the circulation

    • An embolus is a detached intravascular solid, liquid or gaseous mass that is carried by the blood to a site distant from origin

    • When an embolus affects pulmonary circulation, it is called a pulmonary embolism, which is a potentially life-threatening disorder

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  • Classification of emboli

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    Embolism can be classified based on the following:

    • Matter of the emboli (solid , liquid, gases, foreign bodies)

    • Whether it is infected on not (Sterile of Septic)

    • The source of the emboli • Cardiac - left atrium and atrial appendages, infarct in the left ventricle,

    vegetations of endocarditis

    • Arterial - systemic arteries in the brain, spleen, kidney, intestine

    • Venous - pulmonary arteries

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  • Classification of Embolism based on matter

    • Thromboembolism (90%)

    • Fat embolism

    • Air embolism

    • Amniotic fluid embolism

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  • Thromboembolism

    • Embolism from a blood clot

    • Thromboembolism makes up 90% of all embolism. It may be arterial or venous.

    • Thromboembolism can travel to various sites – lungs, brain, kidneys, spleen

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  • Fat Embolism

    • Obstruction of arterioles and capillaries by fat globules • Fractures of long bones

    • Trauma to soft tissue e.g., adipose tissue

    • Clinical features

    • Pulmonary insufficiency - tachypnea, dyspnea, tachycardia

    • Neurologic symptoms - irritability, restlessness to delirium and coma

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  • Air embolism

    • Embolism occurs when air is introduced into venous or arterial circulation. Gas bubbles within the circulation can coalesce to form frothy masses and obstruct vascular flow. Can occur in the following situations: • Small volume of air trapped in coronary artery during bypass surgery

    • Chest wall injury

    • Obstetric or laparoscopy procedures

    • Surgery on head and neck, cardiothoracic surgery

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  • Amniotic fluid embolism

    • Amniotic fluid flows into ruptured uterine vessels.

    • Infusion of amniotic fluid or foetal tissue into maternal circulation via a tear in placenta membranes and uterine veins. It is uncommon.

    • The amniotic fluid triggers serious reaction leading to cardiorespiratory collapse and massive bleeding

    • Can occur during labour or immediately post partum

    • Cli

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