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Introduction
Pathophysiology Risk Factors Symptoms Lab Findings Radiology Findings Treatment Prevention
Pathophysiology
Dislodgement of a blood clot: Lower Extremities: 65% to 90% Pelvic venous system Renal venous system Upper Extremity Right Heart
Wells Criteria
Clinical Signs and Symptoms of DVT? +3 (Calf tenderness, swelling >3cm, errythema, pitting edema affected leg only)
+3
+1.5 +1.5 +1.5 +1 +1
>6: 2 to 6: 2 or less:
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.
Symptoms of P.E.
Dyspnea Pleuritic pain Cough Hemoptysis (blood tinged/streaked/ pure blood)
Signs of P.E.
Tachypnea Rales Tachycardia Hypoxia S4 Accentuated pulmonic component of S2 Fever: T <102 F
S1Q3T3!!!
RAD
Right Atrial Enlargement
CXR:
Whats This???
Hamptons Hump
Hypercoagulability Work Up
No consensus on who to test Increased likelihood if:
Age <50y/o without immediate identifiable risk factors (idiopathic or provoked) Family history Recurrent clots If clot is in an unusual site (portal, hepatic, mesenteric, cerebral) Unprovoked upper extremity clot (no catheter, no surgeries) Patients with warfarin induced skin necrosis (they may have protein C deficiency
Hypercoagulability Work Up
Protein C/S deficiency Factor V leiden deficiency AntiThrombin III deficiency Prothrombin 20210 mutation Antiphospholipid antibody High Homocysteine
Treatment of P.E.
Respiratory Support: Oxygen, intubation Hemodynamic Support: IVF, vasopressors Anticoagulation Thrombolysis IVC Filter
Anticoagulation
Start during resuscitation phase itself If suspicion high, start emperic anticoagulation Evaluate patient for absolute contraindication (i.e.: active bleeding)
Anticoagulation (contd)
HEPARIN:
Lovenox: if hemodynamically stable, no renal function
1mg/kg BID OR 1.5mg/kg QDay
COUMADIN:
Start once acute anticoagulation achieved Start with 5mg PO qday OR 10mg PO q day If start with 10mg then achieve therapeutic INR 1.4 days sooner Complications and morbidity no different in 5mg or 10mg start Goal INR 2 to 3
Duration
At least 3 mos
Strength of Recommendation
A
A B
6 to 12 weeks
Thrombolysis
Considered once P.E. diagnosed If chosen, hold anticoagulation during thrombolysis infusion, then resumed Associated with higher incidence of major hemorrhage Indications: persistent hypotension, severe hypoxemia, large perfusion defecs, right ventricular dysfunction, free floating right ventricular thrombus, paten foramen ovale Activase or streptokinase
IVC Filter
Indication:
Absolute contraindication to anticoagulation (i.e. active bleeding) Recurrent PE during adequate anticoagulation Complication of anticoagulation (severe bleeding)
Also:
Pts with poor cardiopulmonary reserve Recurrent P.E. will be fatal Patients who have had embolectomy Prophylaxis against P.E. in select patients (malignancy)
Embolectomy
Surgical or catheter Indication:
Those who present severe enough to warrant thrombolysis In those where thrombolysis is contraindicated or fails
Questions?