ALMANA GROUP OF HOSPITALS

VENOUS THROMBOEMBOLISM

VTE

DAMMAM

Dr. AHMED ELAMIN AWADELKARIM

MEDICAL RESIDENT

AHMEDELAMINELSIDDIG

OBJECTIVES Overview of VTE. Risk factors. Scoring systems. DVT diagnosis and management. PE diagnosis and management. Special situations.

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

overview

DVT

Internal Medicine Dpt.

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.

Well’s score for DVT

Internal Medicine Dpt.

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.

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.

Nice guidance for DVT

Internal Medicine Dpt.

Pulmonary Embolism P.E

Internal Medicine Dpt.

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.

IN ADDITION PREVIOUS DVT

Internal Medicine Dpt.

OVERVIEWClot travels from deep veins, RV then pulmonary arteries

Blood flow obstructed

Tissue necrosis

Symptoms result

Internal Medicine Dpt.

PRESENTATIONShortness of breathChest pain (+/- pleuritic)SyncopeHemoptysisMay mimic pneumonia (if lung infarction)TachycardiaHypoxiaElevated JVP (or distended jugular veins)DVT symptoms

Internal Medicine Dpt.

WELL’S SCORE FOR PE

Internal Medicine Dpt.

NICE GUIDANCE FOR PE

Internal Medicine Dpt.

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.

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.

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.

SINUS TACHY+RBBB+T INVERSION V1-3

Internal Medicine Dpt.

RBBB+S1Q3T3+R axis deviation

Internal Medicine Dpt.

chest x-ray

NORMAL

HAMPTON’S SIGN

WESTERMARK’S SIGN

Internal Medicine Dpt.

Internal Medicine Dpt.

Internal Medicine Dpt.

Internal Medicine Dpt.

CTPA

Internal Medicine Dpt.

VQ SCAN

Internal Medicine Dpt.

Management

Internal Medicine Dpt.

Management

Internal Medicine Dpt.

ManagementShould I start?? Which one??Appropriate dose??How I monitor??How long??

Patient is stable or not??

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.

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.

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.

PREVENTIONAGH POLICY

Internal Medicine Dpt.

THANK YOU

FOLLOW AHMEDELAMINELSIDDIG

Internal Medicine Dpt.