Deep Vein Thrombosis And Peripheral Thrombphlebitis Flashcards
DVT=
🔸Blood clot that form in a deep vein in the body , most of the clots occur in the lower leg or thigh
🔸often resulting in a potentially life threatening emboli in the lungs or debilitating valvular dysfunction or chronic leg swelling (post thrombotic syndrome)
3 factors that are critically important in the development of venous thrombosis:
🔸these factors named VIRCHOW TRIAD
(1) venous stasis
(2) hypercoagulability
(3) vein damage
Etiology for DVT:
1.major surgeries ( hip or knee replacement, pelvic surger)
2.fractures
3.immobility
4.cancer+- chemotherapy
🔸risk factors can be subdivided by duration:
-Transient ( leg fracture , surgery, pregnancy, use if OC)
-long term ( conginetal antithrombin deficiency, cancer)
*distal DVTs more frequently related to transient situations while proximal to chronic
Clinical manifestations:
1)spontaneous pain
2)induced pain ( walking, compression, positive homan’s sign )
3)edema : phlegmasia alba dolnes (painful white edema, milk leg, total occlusion of deep ileofemoral veinous system ), phlegmasia cerulea dolens ( painful blue appearance of the leg , occurs due to massive thrombosis involving major and collateral vein of the leg )
___________
Signs and symptoms:
Calf or thigh pain , tenderness , swelling, or superficial venous dilation ( not specific for DVT)
Imaging diagnosis DVT=
▪️compression venous ultrasonography+- doppler
▪️magnetic resonance venography ( high specificity and sensitivity for proximal DVT), EXPENSIVE
▪️contrast venography ( is the reference standard )
1ST LINE IMAGING
Lab findings of DVT:
▪️D-dimer : elevated in plasma
*exclude VTE when levels are not raised
DDX: sepsis , pregnancy, surgery and cardiac/renal failure ( also can cause elevated D-dimer
The wells score :
Is a number that reflects the risk of developing DVT
3 level WELLS SCORE:
▪️low risk <2
▪️intermediate 2-6
▪️high risk >6
2 level WELLS SCORE:
▪️unlikely <1
▪️likely>2
*PE unlikely 0-4
*PE likely >4
———————
*active cancer 1️⃣
*Paralysis, paresis or plaster immobalization of the lower extremitiy 1️⃣
*recent bedridden for 3 days or more , major surgery within the prev 12 weeks1️⃣
*localized tenderness along the distribution of DV system1️⃣
*entire leg swelling1️⃣
*calf swelling at least 3cm larger than that one asymptomatic leg 1️⃣
*pitting edema confined to the symptomatic leg1️⃣
*collateral superficial veins1️⃣
*prev documented DVT1️⃣
*alternative diagnosis at least as likely as DVT -2️⃣
*
Differential diagnosis with DVT:
- muscle strain
- direct twisting injury to leg
- leg swelling in paralyzed limb
- lymphaginitis, lymphatic obstruction
- venous reflux
- muscle tear
- baker cyst
- cellulitis
- internal abnormality of the knee
Treatment :
✅anticoagulation (standard therapy): 🔹oral direct thrombin and factor xa inhibitors:
RIVAROXABAN= 15 mg twice daily for 3 wks followed by 20 mg/day
APIXABAN=10mg twice a day for 1 wk followed by 5 mg 2/day
🔹heparin:
unfractionated heparin(iv)= must be given as a continuous infusion, aPTT should be monitored ( iv bolus 5000 IU, iv infusion 15,000 IU over 12 hrs)
low mulecular weight heparin= sc( once or twice daily)
DALTEPARIN
ENOXAPARIN
NADROPARIN
TINZAPARIN
🔸no aPTT needed, dosage depends on patients weight
* does not lyse the clot, prevent clot formation/ extension
✅thrombolysis /thrombectomy - mechanical thrombus removal alone is not successful and needs adjuvant thrombolytic therapy
OTHER ANTICOAGULANTS:
🔹acenocumarol initiate 4-6mg/day
🔹warfarine initiate 5-10mg/day
*they inhibit the production of clotting factors 2,7,9,10,
The goal of INR ratio is 2-3
🔹DOAC= DABIGATRAN, APIXABAN, RIVAROXABAN, EDOXABAN
✅vena cava filter
✅compression= elastic compression stockings
Oral direct thrombin and factor Xa inhibitors:
✅rivaroxaban: 15 mg twice daily for 3 weeks followed by 20
✅apixaban: 10mg twice daily for 7 days followed by 5 mg twice daily
Administration of UF heparin:
1) Iv bolus 5,000 IU
2) iv infusion 15,000 IU over 12 hrs
3) check aPTT ratio
Low molecular weight Heparin:
✅dalteparin ✅enoxaparin ✅nadroparin ✅tinzaparin ✅fondaparinux *sc (once or twice daily)
Antivitamin K anticoagulants:
1)acenocumarol initiate 4-6 mg/day
2)warfarine initiate 5-10mg/day
▪️Mechanism: inhibit the production of clotting factors II, VII, IX , X
Transition to oral treatment ;(DOAC):
Dabigatran: 150 mg twice daily
Apixaban 5mg twice daily
Rivaroxaban 20 mg/ day
Edoxaban 60mg/day
Side effects of anticoagulants :
Bleedings Major bleeding( intracranial, GI or retroperitoneal) leading to hospitalization, transfusion or death
DVT prevention:
🔸surgery 🔸major trauma 🔸prolonged bedrest or 🔸immobilization >72hrs 🔸 previous episodes of VTE 🔸 presence of malignant disease 🔸paralysis 🔸morbid obesity 🔸increasing age ✅mechanical prophylaxis ✅low dose fractionated heparin ✅low dose oral DOAC
Pulmonary Embolism=
Describes the blockage of a pulmonary artery or one of its branches by a blood clot or foreign material
-pulmonary thromboembolism is not a disease in and of itself, rather its a complication of underlying venous thrombosis
Clinical manifestation of PE:
▪️abrupt onset of pleuritic chest pain ▪️shortness of breath ▪️hemoptysis ▪️fever ▪️syncope and seizures ▪️cardiogenic shock ▪️new onset atrial fibrillation ▪️tachycardia >100 bpm, cyanosis , hypoxemia ▪️distended jugular veins ( right HF) ▪️pulmonary rales
Paraclinical investigations PE:
🔸D-dimer testing in plasma 🔸thoracic radiography 🔸ECG 🔸echocardiography 🔸CT pulmonary angiography 🔸MRI 🔸pulmonary angiography( GOLD DTANDARD) 🔸ECG, acute cor pulmonary 🔸echocardiography ( dilated R atrium and ventricle , moderate tricuspid regurgitation , elevated PA pressure <55mmhg
Treatment of PE:
✅medical treatment -fibrinolytic therapy -anticoagulation therapy ✅mechanical reperfusion -percutaneous catheter embolectomy ✅surgical reperfusion
Fibrinolytic therapy in PE:
-should be used in pts with acute PE associated with hT (systolic<90mmHg)
✅streptokinase (250,000 IU as loading dose over 30 min)
✅tissue plasminogen activator (actilyse) 100mg over 2 hrs
