DVT Flashcards
Sequelae of DEEP VEIN THROMBOSIS
✨ PULMONARY EMBOLISM
✨ POST THROMBOTIC LIMB
Virchow’s TRIAD
🧠⚡SHE ⚡
S : Stasis
H : HYPERCOAGULABLE state
E : Endothelial Dysfunction
Virchow in MEDICINE
🌟 Virchow: FATHER OF MODERN PATHOLOGY
🌟 Virchow’s TRIAD: Stasis + Hypercoagulability + Endothelial dysfunction
🌟 Virchow’s Node: Left Supraclavicular node
🌟 Virchow’s method of Autopsy: Organs are removed 1 by 1
🌟 Virchow’s CELL: MACROPHAGE IN LEPROSY (HENSEN’S DISEASE)
🌟 Virchow’s disease: LEONTIASIS OSSEA (Symptom)
🌟 Virchow’s Line: Line from ROOT OF NOSE to LAMBDA
🌟 Virchow’s Metamorphosis: Lipomatosis in Heart and Salivary Gland
🌟 Virchow’s LAW: During CRANIOSYNOSTOSIS: Skull growth is restricted to plane perpendicular to the affected, prematurely fused suture and is enhanced in a plane parallel to it
🌟 Virchow Robin SPACE: Enlarged Peri-Vascular Spaces (EPVS) Space surrounding the blood vessels for a short distance as they enter the BRAIN
🌟 Virchow-Seckel syndrome: BIRD HEADED DWARFISM
HYPER-COAGULABLE STATES
🧠⚡CALM³ SH²APES² ⚡
- C protein deficiency
- APLA syndrome
- Leiden FACTOR V Mutation
- Malignancy
- Myocardial INFARCTION
- MTHF gene mutation
- S Protein deficiency
- Hyperhomocystinemia
- HEPARIN induced Thrombocytopenia
- Antithrombin deficiency
- Prothrombin G20210A mutation / PREGNANCY
- EIGHT Factor deficiency
- Sticky Platelet SYNDROME
- Surgery & Trauma
⚡⚡ MOST IMPORTANT RISK FACTOR for DVT
Admission into HOSPITAL for Medical (OR) Surgical Treatment
Cause of HYPER-COAGULABLE STATE AFTER SURGERY (OR) TRAUMA
Large quantity of Tissue Factors is RELEASED
⬇️
ADHESIVENESS of Platelets ⬆️
⚡⚡ MOST COMMON Congenital PROTHROMBOTIC STATE
Factor V Leiden Mutation
MAY THURNER SYNDROME
🧠⚡ MA-LE⚡
LEft Iliac Vein Thrombosis
⭐ DUE TO: Right Iliac Artery pressure
DVT is MOSTLY U/L or B/L?
U/L
⚡⚡ MOST COMMON VEIN AFFECTED IN DVT
Calf or SOLEAL Veins
⚡⚡ MOST COMMON VEINS involved in DVT leading to PULMONARY THROMBOEMBOLISM
Iliofemoral veins
(Supra-popliteal veins)
⚡⚡ MOST COMMON SYMPTOM OF DVT
⚡⚡ EARLIEST SYMPTOM OF DVT
⭐ PAIN & SWELLING
⚡⚡ MOST CONSTANT SIGN OF DVT
Limb Edema
Which DVTs are usually ASYMPTOMATIC
Calf DVT
MOSES’S SIGN
(OR)
BANCROFT SIGN
Squeezing the CALF ➡️ Pain
HOMAN’S SIGN
🧠⚡Human is DuFuR ⚡
Dorsiflexion of Foot ➡️ RESISTANCE (OR) STIFFNESS
Homan’s sign vs Hamman’s sign vs HOMAN’S Procedure
Homan Procedure: In LYMPHEDEMA management: Skin & SUBCUTANEOUS tissue is REMOVED
PHLEGMASIA CERULEA DOLENS
(PAINFUL BLUE LIMB)
🧠⚡ C = 3⚡
Major AXIAL VEIN(1) ➕ COLLATERALS (2)
Occlusion of both Superficial & Deep Venous System.of Leg
⬇️
Venous Gangrene
PHLEGMESIA ALBA DOLENS
🧠⚡ A = 1⚡
Thrombosis of
⭐ MAJOR AXIAL VEINS
⭐ COLLATERALS NOT INVOLVED
MODIFIED WELL’S CRITERIA
⭐️ ABCD(CD)E(CDE) – 4P ⭐️
⭐️Rule of 3 – Note the 3 sets of 3:
1. Bedridden for >3 days in 1 month
2. Major surgery in last 3 months
3. More than 3 cm calf enlargement ⭐️
A: Alternate diagnosis of DVT more likely (-2)
B: Bedridden recently >3 days or Big (major) surgery within 3 months (+1)
C: Cancer – treatment or palliation within 6 months (+1)
D: Deep venous involvement:
Mnemonic – CD
Collateral (non-varicose) superficial veins present (+1)
Deep venous system tenderness (+1)
E: Edema:
Mnemonic – CDE
Calf swelling > 3cm compared to other leg – measured 10 cm below tibial tuberosity (+1)
Denting (pitting) edema of involved leg (+1)
Entire leg swollen (+1)
4 P:
Paralysis, Palsy or Plaster immobilization (+1)
Previous documented DVT (+1)
🩺 IOC for DVT
🩺 IOC for PULMONARY EMBOLISM
⭐ Duplex Scan
(Color Doppler ➕ B-mode USG)
⭐ CT ANGIOGRAPHY
INDICATIONS of MRI in DVT
DVT in ILIAC or FEMORAL VEIN
GOLD STANDARD INVESTIGATION for DVT
GOLD STANDARD INVESTIGATION for PULMONARY EMBOLISM
⭐ VENOGRAPHY
⭐ PULMONARY ANGIOGRAPHY
💊💉 MANAGEMENT of DVT
✨ 1st 5 DAYS
✨ Next 5 DAYS
✨ 1st EPISODE
✨ RECURRENT
⭐ ANTICOAGULATION
✨ 1st 5 DAYS
🎯 WARFARIN ➕ HEPARIN (LMWH)
✨ Next 5 DAYS
🎯 WARFARIN
✨ 1st EPISODE
🎯 WARFARIN X 3 months
✨ RECURRENT
🎯 LIFELONG WARFARIN
TRANSIENT PROTHROMBOTIC STATE is seen with
WARFARIN
⭐ Fall in Protein C & Protein S
Warfarin Therapy is MONITORED by
INR
Target INR for WARFARIN
2-3
NORMAL INR
🧠⚡ P-PC⚡
= Prothrombin Time of Patient / Prothrombin Time of Control
🤢😳SIDE EFFECTS🥴😵 of WARFARIN
🧠⚡BHAST⚡
- Bleeding
- Bluish discolouration of Feet
- HIT worsens
- Alopecia
- Skin Necrosis ➡️ Breast, Buttocks, Thigh
- Teratogenic
➡️ Nasal Hypoplasia
➡️ Stippled Epiphyseal CALCIFICATION
Maximum permissible value of INR at which SURGERY can be dome WITHOUT ⬆️ HIGH RISK of Bleeding is
1.4
To reduce INR quickly
Prothrombin Factor Concentrates > > FFP
Pregnancy & ANTICOAGULANTS
NOAC
Factor Xa inhibitors ➕ Oral Direct Thrombin inhibitors
🧠⚡ BEAR⚡
- Betri-xa-ban
- Epi-xa-ban
- Api-xa-ban
- Rivaro-xa-ban
Oral Direct Thrombin inhibitors
1. Dabigetran
2. Ximelagetran
ATTRACT Trial for
Thrombolysis is useful in patient with PROXIMAL (ILIAC/FEMORAL Vein) DVT with MODERATE to Severe Symptoms
⚡⚡ MOST COMMON USED IVC FILTER
Greenfield Filter
Identify
IVC Filter
(Inferior Vena Cava Filter)
Prevents Thrombi moving UPWARD
INDICATIONS FOR VENA CAVA FILTER
🧠⚡APPP ⚡
- ANTICOAGULANTS are 🚫 CONTRAINDICATION
- Pulmonary HYPERTENSION
- PULMONARY EMBOLISM despite ANTI-COAGULATION
- Propagating ILIO-FEMORAL VENOUS THROMBUS in ANTICOAGULATION
- Complications of ANTICOAGULANTS ➕
COMPLICATIONS of IVC FILTERS
- Migration of filter
- Bleeding
- IVC Blockade
💊💉 MANAGEMENT of IVC BLACKADE
IV Fluids
POST-THROMBOTIC LEG
⭐ VELP
- Varicose vein
- Edema
- Lipodermatosclerosis: CHAMPAGNE BOTTLE Appearance
- Pigmentation
Risk factors for POST-THROMBOTIC LIMB
⭐ EXTENSIVE DVT
⭐ PROXIMAL DVT
⭐ SUB-THERAPEUTIC ANTICOAGULATION
HIGH-RISK PATIENT GROUOS FOR VENOUS THROMBOEMBOLISM
- MAJOR ORTHOPEDIC SURGERY, # of HIP, PELVIS, LOWER LIMB
- MAJOR ABDOMINAL (OR) PELVIC SURGERY for CANCER
- MAJOR SURGERY, TRAUMA, MEDICAL ILLNESS IN PATIENTS WITH DVT, PULMONARY EMBOLISM (OR) THROMBOPHILIAs
- LOWER LIMB PARALYSIS (Stroke, Paraplegia)
- Major Lower Limb Patients
WHICH PATIENT GROUP recieves DUAL PROPHYLAXIS
Moderate & HIGH RISK patients
Dual PROPHYLAXIS
Mechanical
➕
Pharmacological
WHICH PATIENT GROUP recieves only MECHANICAL PROPHYLAXIS
Low risk
MECHANICAL PROPHYLAXIS
- Early Ambulation
- Pneumatic Compression
- Stockings
PHARMACOLOGICAL PROPHYLAXIS
LMWH
✨ Longer T½
✨ SC
✨ NO MONITORING REQUIRED
SITTING FROM LYING DOWN after SURGERY ⬆️ RISK OF
PULMONARY EMBOLISM
Identify
PNEUMATIC COMPRESSION STOCKINGS
1° UPPER LIMB DVT is known as
PAGET SCHROTTER DISEASE
(AXILLARY VEIN THROMBOSIS)
PAGET SCHROTTER DISEASE
Seen in
AXILLARY VEIN THROMBOSIS
⭐ ATHLETES with REPETITIVE ARM MOVEMENTS
⬇️
Weight Lifters
Javelin Throwers
2° UPPER EXTREMITY DVT
✨ INDWELLING CATHETER
✨ CANCER
🧑🏻⚕️ Clinical Features
UPPER EXTREMITY DVT
✨ PAIN
✨ SWELLING
✨ EDEMA
🩺 IOC of UPPER LIMB DVT
Duplex Scan
⚡⚡ MOST COMMON COMPLICATION OF IV Line
SUPERFICIAL THROMBOPHLEBITIS
PAINFUL CORD LIKE SWELLING is seen in
SUPERFICIAL THROMBOPHLEBITIS
💊💉 MANAGEMENT of SUPERFICIAL THROMBOPHLEBITIS
✨ ANTI-INFLAMMATORY AGENT
✨ THROMBOPHOBE OINTMENT
✨ COMPRESSION GARMENTS
ECONOMY CLASS SYNDROME
THROMBOEMBOLISM DUE TO: LONG TIME FLIGHT TRAVEL > 8 hrs
PROXIMAL DVT
vs
DISTAL DVT
✨ More dangerous (because of ⬆️ risk of PULMONARY EMBOLISM & Death)
✨ POPLITEAL VEINS or Above
✨ Femoral or Iliac Veins
⭐ LESS DANGEROUS
⭐ BELOW POPLITEAL VEINS
50% RULE in DVT
Only 50% Symptomatic
⬇️
50% pts have ASYMPTOMATIC PULMONARY EMBOLISM
PRATT Sign seen in
⭐ DVT
In prone position
⬇️
Squeeze BOTH the calves
⬇️
Give PRESSURE on the POPLITEAL VEIN & PROXIMAL ASPECT @ SAME TIME
⬇️
PAIN
Identify the SIGN
⬆️ PRESSURE of Legs by SPHYGMOMANOMETER
⬇️
PAIN
NEUHOF’S Sign
Seen in
⭐ DVT
Squeezing the Calf
⬇️
Pain
✨ Muscles will be THICKENED DUE TO: Edema
LINTON’S SIGN seen in
⭐ Procedure
DVT
Tourniquet tied at SAPHENO-FEMORAL Junction
⬇️
Patient asked to walk
⬇️
Lift the affected limb up
⬇️
Dilatation of Deep vein
MODIFIED VILLALTA SCORE used for
⭐ POST-THROMBOTIC LEG
Diagnosis & GRADING
LOWENBERG’S SIGN
Seen in
DVT
⬇️
Pain is ➕ when a blood pressure cuff is placed around the calf & inflated to 80mm Hg
MAY THURNER SYNDROME
Synonyms
- Iliocaval Venous Compression Syndrome
- Iliac Vein Compression Syndrome
- Cockett’s syndrome
- Venous spur