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Thromboprophylaxis following S pinal C ord I njury. C P Vinod Duke of Cornwall Spinal Treatment Centre, Salisbury. Objectives. Venous Thrombo-Embolism (VTE) Spinal Cord Injury (SCI) Thromboprophylaxis following SCI. Venous Thrombo -Embolism. Blood Flow is essential for Life Arteries
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Thromboprophylaxis following Spinal Cord Injury C P Vinod Duke of Cornwall Spinal Treatment Centre, Salisbury
Objectives • Venous Thrombo-Embolism (VTE) • Spinal Cord Injury (SCI) • Thromboprophylaxis following SCI
Venous Thrombo-Embolism • Blood Flow is essential for Life • Arteries • Veins • Capillaries • Clotting of blood is also essential for life! • Thrombus – Blood Clot • Emboli – dislodged Clot
Venous Thrombo-Embolism (VTE) • Pathophysiology • Virchow’s Triad
Venous Thrombo-Embolism (VTE) • Pathophysiology • Virchow’s Triad • Haemodynamic Changes • Cardiac • Artificial Valves • Atrial Fibrillation • Atherosclerosis • Plaques • Immobility • Bed Rest • Paralysis
Venous Thrombo-Embolism (VTE) • Pathophysiology • Virchow’s Triad • Haemodynamic Changes • Hypercoagulability • Dehydration • Infections • Malignanacy
Venous Thrombo-Embolism (VTE) • Pathophysiology • Virchow’s Triad • Haemodynamic Changes • Hypercoagulability • Endothelial Injury • Trauma • Surgery
Venous Thrombo-Embolism (VTE) • Pathophysiology • Virchow’s Triad • Haemodynamic Changes • Hypercoagulability • Endothelial Injury
Venous Thrombo-Embolism (VTE) • Thrombosis/Emboli in Arteries • Stroke • Infarct • Ischemia • Thrombosis/Emboli in Veins (VTE) • Deep Vein Thrombosis • Pulmonary Embolism
SCI - Epidemiology • Incidence - 11 to 40 per million • Prevalence – 10,000 in UK • 50% of SCI seen in 16 – 30 years age group • Median age 26 years • Traumatic SCI more common in <40 age group • Non-traumatic SCI more common in >40 age group
Tetraplegia C8 and above C4 and above may be ventilator dependent Paraplegia T1 and below Below L3 may be able to walk Complete Incomplete Syndromes Central Cord Brown-Sequard Anterior Cord Cauda Equina Conus Medullaris SCI Classification
SCI - Mortality/Morbidity • 1927 – Harvey Cushing described 80% mortality in WW 1 soldiers with SCI • Renal Failure & Pressure Sores • Today – In well organised centres 94% survive initial hospitalisation • Pneumonia, PE & Septicaemia
Thromboprophylaxis in SCI • All patients have thromboprohylaxis for at least 12 weeks post spinal cord injury (Unless contraindicated) • We use LMWH
Thromboprophylaxis in SCI • Clinical Practice Guidelines (CPG) for Spinal Cord Injury • Published by the Consortium for Spinal Cord Medicine
Thromboprophylaxis in SCI • Second Edition Published in Sep 1999 • First edition 1997
Thromboprophylaxis in SCI • Why is it so high following SCI? • Failure of Venous muscle pump • Transient hypercoagulable state • Alteration in Haemostasis • Reduced fibrinolytic activity • Increased factor VIII activity • Dehydration • Other injuries
DVT relative to time Post SCI • 80% unprophylaxed patients develop DVT within the first 2weeks • Rossi et al 1980; Merli et al 1993 • 6% incidence at 8 week following stopping of prophylaxis • Green et al 1994
Thromboprophylaxis in SCI • Incidence of PE not influenced by degree or level of SCI • Ragnarsson et al 1995 • Post Thrombotic Syndrome seen in over 60% • Chronic oedema, induration, Skin ulceration • Monreal et al 1993
Mortality due to VTE in SCI • Autopsy in Acute SCI deaths -37% due PE • Tribe et al 1963 • Pulmonary Embolism • 3rd leading cause of death in Paraplegia • 2nd leading cause of death in Incomplete SCI • DeVivo and Stover 1995 • Risk of death due to PE in acute SCI • 210 times greater than healthy population • Decreases to 8.9 times after 5 years
Thromboprophylaxis in SCI • VTE in SCI is a silent killer • Thromboprophylaxis (Mechanical or/and Pharmacological) if in doubt • Contact the nearest Spinal Injuries Centre
Thromboprophylaxis in SCI Thank You