Case 7: Leg Swelling Flashcards
What is the single greatest contributor to death in the United States?
SMOKING
Three leading causes of smoking attributable death
- Lung cancer
- Ischemic heart disease
- COPD
Uncontrolled hypertension reduces life expectancy by
20 years
Four causes of hypertensive attributable death
- Coronary artery disease
- Hypertensive cardiomyopathy
- Cerebrovascular disease
- Chronic renal disease
Two causes of diabetic attributable death
- cardiovascular disease
- chronic renal failure
Risk of cardiovascular disease in diabetics is so high, it is assumed that
they have cardiovascular disease if they have diabetes
Second most common cause of death in United States
Obesity
- reduces life expectancy by 6-7 years
____% of PE are due to DVT
95%
PE carries high mortality (90% of deaths happen within first 2 hours) - so prevention and prompt Tx of DVT is key to reducing death as PE consequence
Half life of warfarin
40 hours
How long does it take for steady state of warfarin to be stable?
5 to 7 days
Foot exam for Diabetic patients
- Sensory testing with 10 g monofilament + any one of following:
- vibration with 128 tuning fork
- illicit Achilles ankle reflexes
- pinprick sensation - Arterial supply assessment with DP/PT pulses + evaluate for skin changes: hair loss and temp changes
- Inspect feet and footwear fit
Strongest risk factor in delayed ulcer healing and amputation
Peripheral vascular disease
Ulcer classification: Wagner Grading System
- Grade 1: Diabetic ulcer (superficial)
- Grade 2: Ulcer extension (involving ligament, tendon, joint capsule or fascia)
- Grade 3: Deep ulcer with abscess or osteomyelitis
- Grade 4: Gangrene forefoot (partial)
- Grade 5: Extensive gangrene of foot
Ulcer management: Grade 1-2
- outpatient: extensive debridement + local wound care + relief of pressure
If erythema + purulent exudate: treat for infection
Ulcer management: Grade 3
Evaluate for a) osteomyelitis and b) peripheral artery dz
- brief hospitalization
Ulcer management: Grade 4-5
Emergent hospitalization + surgery consult –> amputation
DDx for unilateral LE edema
- lymphedema
- cellulitis
- DVT
- venous insufficiency
- peripheral artery disease
Lymphedema
Painless or dull heavy sensation in leg
- early stage: pitting
- chronic stage: limb has woody texture, tissue becomes indurated and fibrotic
Cellulitis
Acute inflammatory infection of skin: erythema, swelling, heat (if small: strep, if large/ulcer/abscess: staph)
- RFs: diabetic nephropathy and PAD
DVT
Swelling, pain, discoloration of affected extremity + palpable cord of thrombosed vein, warmth
- can result in chronic venous insufficiency (valves become thickened or high pressures distend vein and separate leaflets)
- pain is worse when standing and relieved w elevation
- inflammatory response in leg - mild fever
Doppler ultrasound is best test
Venous insufficiency
Pitting edema + erythema + dermatitis + hyperpigmentation + skin ulceration near medial and lateral malleoli
Peripheral artery disease
Atherosclerosis in peripheral vessels
- claudication
- ABI < 0.9
- greatest modifiable risk factor: smoking
Most significant independent risk factors for DVT
- smoking
- obesity
Wells criteria for Dx of DVT
Each +1 (8)
One is -2 (other dx is more likely than DVT)
Positive criteria
- active cancer
- paralysis, paresis, recent plaster immobilization of leg
- recently bedridden >3 days or major surg w/in 4 wks
- local tenderness along distribution of venous system
- entire leg swollen
- affected leg is swollen >3 cm compared to Asx leg
- pitting edema > in Sx leg
- collateral superficial veins (non-varicose)
In order for DVT to be treated on outpatient basis:
3 patient reqs
2 home reqs
Patient reqs
- hemodynamically stable
- good kidney fxn
- low risk for bleeding
Home reqs
- stable and supportive
- daily access to INR monitoring
Heparin allows for
Immediate inhibition of growth of thromboemboli by allowing fibrinolytic dissolution to be achieved unopposed
Why is LMWH > unfractioned heparin
- longer biologic halflife (subQ once daily)
- no lab monitoring required
- thrombocytopenia is less likely
- dosing is fixed
- can be used in outpt setting
Unfractionated heparin requires hospitalization as it is administered IV with dosage based on weight and titrated based on activated PTT
LMWH can be substituted with
Fondaparinux (factor Xa inhibitor)
Thromboprophylaxis can be achieved with
a) Warfarin
b) Factor Xa inhibitor
Warfarin monitoring and titration
Titrate dose every 7 days to INR of 2-3
Factor Xa inhibitors
Do not require weekly lab monitoring of INR so adherence is easier, but more expensive and harder to reverse anticoagulation in face of bleed
First DVT or PE that is provoked by surgery or nonsurgical transient risk factor – anticoagulate for?
3 months
First DVT/PE that is unprovoked but bleeding risk is high, anticoagulate for?
3 months
First DVT/PE that is unprovoked and bleeding risk is low/moderate, anticoagulate for?
Extended period of time
First DVT/PE that is unprovoked and due to active cancer, anticoagulate for?
Extended period of time
Patients with inherited coagulation disorders are anticoagulated
Indefinitely after episode of thrombotic disease
Workup patient for inherited thrombophilia if (4)
- Initial thrombosis when <50 without immediately identified RF
- Family Hx of VTE
- Recurrent venous thrombosis
- Thrombosis in unusual vascular beds: portal, hepatic, mesenteric, cerebral veins
If goal INR is substantially overshot…
- Hold warfarin
- Give ORAL dose of Vitamin K to reduce INR
If INR 5-9 - dc wafarin, give oral K, repeat INR in 24 hrs
How long to give LMWH, unfractioned heparin, or fondaparinux for as bridge to warfarin?
For at least five days + until INR is >2 for at least 24 hrs
