1 / 67

Ariya.E.K 2002 batch

A 35 year old female patient underwent a pelvic surgery complains of low grade fever and swelling in left lower limb. O/E :- The limb is red and swollen with local rise in temperature , calf muscle tenderness present ,Homan’s sign positive. What is your diagnosis?. How will you proceed?.

gremillion
Download Presentation

Ariya.E.K 2002 batch

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. A 35 year old female patient underwent a pelvic surgery complains of low grade fever and swelling in left lower limb. O/E :- The limb is red and swollen with local rise in temperature , calf muscle tenderness present ,Homan’s sign positive. What is your diagnosis?. How will you proceed?.

  2. MANAGEMENT OF DEEP VEIN THROMBOSIS Ariya.E.K 2002 batch

  3. DIAGNOSIS

  4. History • Diagnosis mainly by high degree of suspicion. • Age . • Family history of VTE. • Past history of VTE.

  5. History of recent trauma. Surgery. Immobility. Pregnancy. Malignancy. air travel.

  6. Clinical Features Only 40% have clinical signs. Signs and symptoms:- In the lower limbs U/l Calf pain & Swelling. Erythema. Dilated sup.veins. Low grade pyrexia. Calf tenderness.

  7. Homan’s sign may be positive. Moses’ sign.

  8. Differential diagnosis • Ruptured Baker’s cyst. • Superficial thrombophlebitis. • Calf muscle hematoma. • Lymphedema.

  9. The same patient who was diagnosed to have deep vein thrombosis suddenly developed breathlessness, what is the probable diagnosis? How will you investigate?

  10. PULMONARY EMBOLISM

  11. Pulmonary Embolism Symptoms:- • Dyspnoea • Anxiety • Pleuritic pain • Cough • Hemoptysis • Syncope

  12. Signs • Tachypnoea • Tachycardia • Accentuated p2 • Rales • S3 or S4 • Pleural rub • Cyanosis • Prominent jugular veins

  13. Differential diagnosis A/C MI Obstructive pulmonary d/ss Pneumothorax Pneumonia Pericarcial d/s Aortic dissection

  14. INVESTIGATIONS

  15. Doppler. • Duplex imaging. • B/l ascending venography. • I-125 Fibrinogen Scan. • Impedance plethysmography. • D-Dimer concentration testing.

  16. DOPPLER ULTRASONOGRAPHY • Thrombus distorts the blood flow. • Normal phasic pattern of flow with respiration will be lost. • Flow augmentation with distal compression will be lost.

  17. DUPLEX • Duplex is thefirst linediagnostic method. • Disadvantage:-Difficult to assess iliac and tibial veins.

  18. Failure of vein to collapse under direct compression. Visualisation of thromus with in the lumen. Absent or abnormal flow. Criteria for diagnosis:-

  19. Bilateral ascending venography • Reference standard for diagnosis of DVT. • Now, second line investigation

  20. I-125 fibrinogen uptake test Principle:- Incorporation of injected I-125 labelled fibrinogen into an evolving thrombus.

  21. Technique:- • An injection of I-125 labelled fibrinogen is given. • Radioactivity is expressed as % of radioactivity measured from the heart. •  of 20% or more indicates an underlying thrombus.

  22. fibrin D D D D D D D-Dimer concentration test. fibrinolytic system

  23. D-Dimer concentration Test • Highly sensitive, but non-specific. • Can be elevated:- • pregnancy • inflammation • advanced age

  24. INVESTIGATIONSif you suspect pulmonary embolism

  25. Chest radiography • ECG • Arterial blood gas analysis • CVP • Ventilation perfusion scan • Pulmonary angiography

  26. Chest radiography • Features suggestive of PE:- Atelectasis. Prominent hilar markings. Pleural effusion. Oligemic lung field (Westermark’s sign) • Wedge shaped opacity-pulmonary infarction

  27. Electrocadiography • To R/o MI • S-wave in lead -1 • Q-wave and inverted T-waves in lead-3

  28. Arterial blood gas analysis • Low PaO2 (<80 mm of Hg) • Low PaCO2 (<36 mm of Hg)

  29. CVP • Low CVP excludes the possibility of PE

  30. ECHOCARDIOGRAPHY • Right ventricular dysfunction. • Intra cardiac clot.

  31. Ventilation perfusion scan • To identify ventilation perfusion mismatch in lung tissue. • I V Technitium is injected. • Radioactivity detected by a camera. • No radioactivity - Embolus

  32. Inhales a radioactive gas (Krypton or Xenon). Distribution is detected by a gamma camera. The ventilation scan in acute PE is usually normal.

  33. Pulmonary angiography • Gold standard. • Essential prior to embolectomy or thrombolytic therapy.

  34. Technique:- A catheter is introduced through the right heart into the pulmonary artery and contrast is injected directly into pulmonary circulation. PE:- intraluminal filling defect. abrupt cut off of pulmonary arterial tree.

  35. High-Res CT SCAN • Quick, accurate and relatively non-invasive. • Valid only for main, lobar, or segmental artery occlusions.

  36. Prophylaxis

  37. All patient admitted to hospital or being treated for a serious illness should be assessed for the risk of DVT. High risk Moderate risk Low risk

  38. High risk patients • >40 yrs. • H/o VTE. • Family h/o VTE. • Malignant d/s. • Pt on OCP/HRT. • Any Sx lasting for >30mts. • Paralysis. • Multiple trauma.

  39. MECHANICAL METHODS Eliminate the venous stasis • Graduated compression stockings (TED). • Sequential pneumatic compression devices. • Leg elevation. • Early ambulation. • Pneumatic boots.

  40. PHARMACOLOGICAL METHODS Altering the blood coagulability • Low dose heparin- 5000U s/c 2hr pre op. & every 12 hr post op. for 6 days. • LMWH. • Dextran-70. • Warfarin-1mg 14 days before operation.

  41. IN LOW RISK GROUP Leg elevation. Early mobilization. IN MODERATE RISK GROUP Leg elevation. Early mobilization. Graduated compression stocking (TEDS) / s.c heparin 5000 U OD.

  42. IN HIGH RISK GROUP Leg elevation. Early mobilization . TEDS. Mechanical calf compression. LMWH.

  43. PREVENTION OF TRAVELLER’S THROMBOSIS • Graduated compression stockings. • Exercise during flight. • Avoid alcohol & sleeping tab. • For high risk passenger-LMWH.

  44. TREATMENT

  45. Pre-requisites…. • Baseline blood urea. • Electrolytes. • LFT. • Coagulation profile. • Thrombophilia screen.

  46. Bed rest with foot end elevation. Anticoagulation. Fibrinolytics. Thrombectomy.

  47. Anticoagulants • Heparin • MOA: Binds ATIII. • Administration: IV or S/c. • C/I: Severe active bleeding. • S/E: bleeding, thrombocytopenia,osteopenia. • Monitoring: APTT.

  48. HeparinAccelerates antithrombin III activity Antithrombin III (Heparin) Factor X Factor IXa Ca2+, PL Factor VIIIa Factor Xa Prothrombin Thrombin Factor Va Ca2+, PL

  49. LMWH MOA: Binds ATIII. Administration: S/C (allows O P treatment). Monitoring: None needed dose is weight dependent. Eg:- Enoxaparin.

More Related