PE and DVT Dr Anzo William Adiga WatsApp or Call +256777363201 Medical Officer/RHEMA MEDICAL GROUP
OBJECTIVES DEFINE DVT AND P.E PATHOPHYSIOLOGY OF DVT CLINICAL PRESENTATION OF DVT/PE INVESTIGATE DVT MANAGEMENT OF DVT/P.E
DEFINATION Deep vein thrombosis (DVT) refers to the formation of one or more blood clots (a blood clot is also known as a thrombus, while multiple clots are called thrombi ) in one of the body's large veins, most commonly in the lower limbs (e.g., lower leg or calf). When Dislodged it becomes Emboli circulating Fb or blood(thromboembolus)
Pathogenesis Virchow s triad: Damage to vessel wall Venous stasis Hypercoagulability
Acquired Risk Factors Age (Old age) Previous thrombosis Immobilization Major surgery especially Ortho Estrogen OCP, HRT, SERMs Antiphospholipid Ab syndrome Malignancy Nephrotic syndrome Inflammatory bowel disease Long distance air travel
Inherited Risk Factors Factor V Leiden mutation Antithrombin deficiency Protein C or S deficiency Dysfibrinogenemia Hyperhomocysteinemia
Clinical Presentation These signs and symptoms occur in the leg affected by the deep vein clot. They include: Swelling of the leg or along a vein in the leg. Pain or tenderness in the leg, which you may feel only when standing or walking. Circumference of leg is about 3cm more than the normal side. See Homan s Sign
Homan s Sign Passive dorsiflexion of the foot with the knee straight may give pain in the calf and back of the knee when there is a deep venous thrombosis. Some concern that vigorous dorsiflexion of the foot can expel clot from the veins and so this test may have its dangers. The sign is not specific for DVT
Fate of a Thromus If it gets Dislodge it becomes thromboembolus circulating in the blood vessel and if gets entraped in the lung it cause Pulmonary Embolism. To the Brain it causes Stroke or CVA Negrosis and Gangrane developed in extremities or any other infarction.
Fate Cont... Due to reduce Blood Supply tissues are denied Oxygen and nutrient their by Starved(Ischaemia) leading to Necrosis (death of affected tissue which later gets Infarcted. Read More about these terms Ischaemia, Necrosis and infarction
Presentation of P.E Dyspnea Pleuritic chest pain Cough +/- hemoptysis On exam may have Tachypnea Tachycardia S4 Loud P2 May have fever rarely In massive PE can have hypotension and shock Look at legs for swelling and Homan s sign but only helpful if positive.
DDX swollen calf DVT Bakers Cyst Cellulitis Gout if really bad it can sometimes look like a cellulitis If bilateral Edema non Tender think about CHF, Nephrotic syndrome, liver failure, venous insufficiency, pregnancy or pelvic mass, vasodilators esp nifedipine
Labs Work outs Check baseline CBC for: PLT number, Leukocytosis Clotting Analysis Clotting time PT PTT INR
CXR May have area of atelectasis May have wedge shaped infarct peripherally Pleural effusion occurs in about 40%
EKG/ECG May have non specific ST and T wave changes Typical SI, QIII, TIII - rare. Sinus tachycardia T wave inversions in right to mid chest leads Poor R wave progression (acute RV dilation) P pulmonale RV conduction delays Right axis shift
Doppler US of lower extremities If high clinical suspicion should be repeated 7-10 days after initial scan as below knee DVT can propagate Also remember that some pt develop DVT s elsewhere so you may not find a DVT in their legs if the source was their arm!
Echo More than 80% of pts with PE will have abnormalities of RV size or function, or TR. McConnells sign regional wall motion abnormalities that spare the R ventricular apex are very suggestive of PE BUT echo is only really used for Dx of massive lifethreatening PE s when rapid diagnosis is needed to determine whether thrombolysis should be given.
V/Q MISMATCH CT SCAN CT Angiogram MRI OTHERS
Treatment Identify any contraindications to anticoagulations if yes then IVC filter Inquire about h/o HIT If yes, then use direct thrombin inhibitor Assess need for hospitalization Extensive iliofemoral DVT with circ compromise Increased risk of bleeding Limited cardioresp reserve Poor compliance CI to LMW heparin
Treatment Administer LMW heparin or unfractionated heparin Goal 1.5-2.5 x PTT in first 24 hours Check platelet count on day 3-5 Treat at least five days and until patient s INR is >2 on coumadin for two consecutive days Start coumadin tabs on day 1
Treatment Duration 3-6 months in most patients Prophylaxis Treatment and Prolongation of treatment is the role of Physician. Role of Daily Cardiac Aspirin 75mg Od increases Life span by 5years
Absolute Contraindications to Active bleeding Anticoagulation Severe bleeding diathesis Platelet count <20 Neurosurgery, ocular surgery or intracranial bleeding within the past 10 days
Relative Contraindications to Anticoagulation Mild/moderate bleeding diathesis or thrombocytopenia Major abdominal surgery within 2 days GI or GU bleeding within 14 days Endocarditis Severe HTN (SBP >200, DBP > 120)
VTE Prophylaxis in Medical Indications Patients CHF or severe respiratory disease Bedrest with additional risk factor Cancer Prior VTE Most ICU patients Options Low dose unfractionated heparin or LMWH Sequential compression devices/physiotherapy Graduated compression stockings Acute neurologic disease Inflammatory bowel disease
Take Home What DVT and P.E mean How does it occur and progress What are the Risk factors for them How to Diagnose DVT/P.E Treatment Prevention of DVT formation