vte venous thromboembolism
TRANSCRIPT
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ALMANA GROUP OF HOSPITALS
VENOUS THROMBOEMBOLISM
VTE
DAMMAM
Dr. AHMED ELAMIN AWADELKARIM
MEDICAL RESIDENT
AHMEDELAMINELSIDDIG
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OBJECTIVES Overview of VTE. Risk factors. Scoring systems. DVT diagnosis and management. PE diagnosis and management. Special situations.
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overview
Medical education does not exist to provide students with away of making living, but to ensure the health of the community.
Rudolf Calr Virchow
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overview
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DVT
Internal Medicine Dpt.
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DVTClassic symptoms includes:
oUnilateral Limb pain and tenderness this may be along the line of the vein.oGeneralized swelling (edematous) of the calf/thigh (unilateral).oHot, erythematous skin.oThere may also be distension of the superficial veins.
Internal Medicine Dpt.
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Well’s score for DVT
Internal Medicine Dpt.
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DIFFERENTIAL DIAGNOSIS•Muscle strain/hematoma•Popliteal cyst•Lymphedema•Cellulitis•Fracture•Chronic venous insufficiency•Proximal venous compression (e.g. tumor)•Congestive heart failure
Internal Medicine Dpt.
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D-DIMER negative- DVT is highly unlikely (High sensitivity).
However positive- it DOES NOT CONFIRM DVT
may be raised in patients with liver disease rheumatoid diseaseInflammationCancerTrauma pregnancy recent surgery
Internal Medicine Dpt.
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Nice guidance for DVT
Internal Medicine Dpt.
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Pulmonary Embolism P.E
Internal Medicine Dpt.
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OVERVIEW600.000 case per year.50.000 deaths per year.Tests is done too much …negative.Most of cases are missed ….autopsy.
Internal Medicine Dpt.
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IN ADDITION PREVIOUS DVT
Internal Medicine Dpt.
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OVERVIEWClot travels from deep veins, RV then pulmonary arteries
Blood flow obstructed
Tissue necrosis
Symptoms result
Internal Medicine Dpt.
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PRESENTATIONShortness of breathChest pain (+/- pleuritic)SyncopeHemoptysisMay mimic pneumonia (if lung infarction)TachycardiaHypoxiaElevated JVP (or distended jugular veins)DVT symptoms
Internal Medicine Dpt.
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WELL’S SCORE FOR PE
Internal Medicine Dpt.
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NICE GUIDANCE FOR PE
Internal Medicine Dpt.
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ABGshypoxemia and hypocapnea (respiratory
alkalosis) due to hyperventilation,
keep in mind arterial blood gas analysis is NOT useful in diagnosis of pulmonary embolism.
Classic finding: hypoxemia and hypocapnea (respiratory alkalosis).Normal ABG: 18% will have PaO2 > 85 mm Hg.Mixed Acidosis: in setting of hemodynamic collapse.
Internal Medicine Dpt.
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Blood InvestigationsFBC (Check WCC)CRPU&Es (check for any signs of electrolyte imbalance or kidney failure which may prevent CTPA)LFTs (check for liver failure that may cause bleeding abnormalities of be a sign of cancer)coagulation screenTroponins could also be considered.
Internal Medicine Dpt.
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ECG CHANGES• sinus tachycardia• Complete or incomplete RBBB (tall R wave in V1 ‘M’; slurred S
wave in V6 ‘W’;MaRRoW)• Right ventricular strain- T wave inversions in right (v1-4)
and inferior (II, III, aVF) leads• Right axis deviation (negative QRS in lead I and aVL and
positive in lead III and aVF)• right ventricular dilation (Dominant R wave in V1 )• Right atrial enlargement (P pulmonale) (>2.5mm peaked P
waves in inferior leads (II, III and aVF) and >1.5mm peaked P wave in V1 and V2)
• S1Q3T3 pattern: deep S wave in lead I, Q wave in III, and inverted T wave in lead III.
Internal Medicine Dpt.
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SINUS TACHY+RBBB+T INVERSION V1-3
Internal Medicine Dpt.
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RBBB+S1Q3T3+R axis deviation
Internal Medicine Dpt.
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chest x-ray
NORMAL
HAMPTON’S SIGN
WESTERMARK’S SIGN
Internal Medicine Dpt.
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Internal Medicine Dpt.
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Internal Medicine Dpt.
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Internal Medicine Dpt.
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CTPA
Internal Medicine Dpt.
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VQ SCAN
Internal Medicine Dpt.
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Management
Internal Medicine Dpt.
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Management
Internal Medicine Dpt.
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ManagementShould I start?? Which one??Appropriate dose??How I monitor??How long??
Patient is stable or not??
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ManagementFor massive PE, thrombolyse unless there are any contraindications Alteplase 50mg stat IV (if imminent cardiac arrest) or 10mg stat IV then 90mg infusion over 120mins
Contraindications includeMajor surgery/trauma in previous 2 weeks; aortic dissection; acute internal bleeding; known cerebral tumour; hx of cerebral bleed/AVM; prolonged/traumatic CPR; pregnancyRelative CI include BP>180/110mmHg; severe renal/liver failure; INR>1.5 from warfarin use or liver disease; current use of warfarin with unknown INR; current use of rivaroxiban; stroke/TIA in last 12 months
Internal Medicine Dpt.
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ManagementNewer agents (mainly factor Xa inhibitors e.g. rivaroxaban)
are now being used in treating DVT/PE15mg BD for 3 weeks then 20mg BD until 3 or 6 months
(provoked/unprovoked respectively)Not used if eGFR<30
not used for >12 months – consider warfarin in those requiring longer term anticoagulation
Offer low molecular weight heparin injection e.g. dalteparin (usually 10000-15000 units per day- based on weight), (or
fondaparinux) to those unsuitable for rivaroxiban
Internal Medicine Dpt.
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ManagementAlso, unfractionated heparin may be preferred in patients with severe renal failure or are haemodynamically unstable.Continue for 5 days or until the INR has been >2 for at least 24 hours (whichever is longer).In patients with cancer, ideally LMWH should be continued for 6 monthsOffer a vitamin K antagonist e.g. warfarin, within 24 hours and continue for 3 months minimum. (see warfarin prescribing)Reassess risk at 3 months- consider further 3 months, particularly if the DVT/PE was unprovoked
Internal Medicine Dpt.
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PREVENTIONAGH POLICY
Internal Medicine Dpt.
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THANK YOU
FOLLOW AHMEDELAMINELSIDDIG
Internal Medicine Dpt.