VENOUS THROMBOEMBOLISM

1. VENOUS THROMBOEMBOLISM Dr. Basheer Khassawneh Associate Professor Pulmonary & Critical Care & Sleep Medicine

2. 55 year old woman presents with sudden dyspnea on exertion and chest pain. No cough, wheeze, or hemoptysis. She had renal cell carcinoma of the left kidney and had left nephrectomy 2 weeks prior to admission. Obese with BMI 38 kg/m2 BP 100/70, HR 120, RR 32, temp 38.1 Chest exam is within normal Heart and abdomen exam within normal Legs: no swelling, no redness ABG: pH 7.48, pCO2 32 mmHG, pO2 65 mmHg ECG: sinus tachycardia CXR: normal

3. Questions What is the likely diagnosis? What are the risks for this problem? What is the pathophysiology? How to confirm the diagnosis? What is the appropriate treatment? Is this problem preventable?

4. Pulmonary Embolism Pneumonia Acute myocardial infarction Pulmonary edema Pneumothorax Pleural effusion Pericarditis Dissecting aortic aneurysm

5. Pulmonary Embolism: Clinical Presentation Dyspnea Chest pain Cough Hemoptysis Dizzines

6. Pulmonary EmbolismPhysical Signs Tachypnea Tachycardia – regular Fever: Temp up tp 38.9°C A fourth heart sound Accentuated P2 Signs of pleural effusion Hypotension

7. Risk factors for Pulmonary Embolism History of DVT/PE Age > 40 Prolonged immobility Stroke Hear Failure Recent surgery Trauma Fractures Venous catheters Nephrotic Syndrome Venous compression Pregnancy Recent delivery Caesarean section Obesity Estrogen Therapy (OCP) Vasculitis, IBD, SLE Cancer Acquired thrombophilia Varicose veins

8. 55 year old woman presents with sudden dyspnea on exertion and chest pain. No cough, wheeze, or hemoptysis. She had renal cell carcinoma of the left kidney and had left nephrectomy 2 weeks prior to admission. Obese with BMI 38 kg/m2 BP 100/70, HR 120, RR 32, temp 38.1 Chest exam is within normal Heart and abdomen exam within normal Legs: varicose veins, no swelling, no redness ABG: pH 7.48, pCO2 32 mmHG, pO2 65 mmHg ECG: sinus tachycardia CXR: normal

9. Questions What is the likely diagnosis? What are the risks for this problem? What is the pathophysiology? How to confirm the diagnosis? What is the appropriate treatment? Is this problem preventable?

10. Deep Vein ThrombosisDVT

11. Pathophysiology Most cases of PE result from lower extremities DVT Proximal DVT (ilio-femoral) is the source of most clinically recognized PE Calf vein DVT may propagate to become a proximal DVT

12. Pathophysiology

13. PE and DVT – One DiseaseVenous ThromboEmbolism Only 30% of patients with PE have symptomatic DVT Asymptomatic PE present in 50% of patients with proven DVT

14. What to do? D-dimer Cardiac enzymes Chest X-Ray Electrocardiogram Arterial Blood Gases V-Q Scan Spiral CT DDX Pneumonia Acute myocardial infarction Pulmonary edema Pneumothorax Pleural effusion Pericarditis Dissecting aortic aneurysm

15. D-DIMERCross-linked Fibrin-degradation products Increased in the presence of active thrombosis Highly sensitive, but nonspecific Elevated in pregnancy, inflammation, advanced age, trauma, post-op, cancer High negative predictive value

16. Chest X-Ray The majority of patients with PE have normal chest radiograph A normal chest X-Ray with severe dyspnea and hypoxemia without evidence of bronchospasm or anatomic cardiac shunt is strongly suggestive of PE Done to rule out other DDx

17. Arterial Blood Gases NOT diagnostic Hypoxemia and elevated A-a gradient Respiratory alkalosis But it can be normal

18. EKG Nonspecific for PE Done to rule out other DDX The most common abnormalities Nonspecific ST segment and T wave changes Right bundle branch block P-wave pulmonale Right axis deviation S1 Q3 T3 pattern

19. Acute Pulmonary EmbolismS1QT3

20. Ventilation/Perfusion Lung scan Nuclear study Ventilation scan – radioactive gas Perfusion scan – radioactive IV contrast Unreliable in the setting of lung disease (pneumonia, cancer, surgery, COPD, asthma) or significant cardiac disease

22. VQ Scan Interpretation

23. Chest CT-Angio Rapid IV contrast Look for filling defect Becoming the procedure of choice Useful – find other lung pathology Contrast nephropathy Not 1st option in renal insufficiency

24. Chest CT-Angio

25. PE - Complications Mortality ~ 12% of PE cases within 1 month of diagnosis. Many patients recover completely after a PE Chronic thromboembolic disease with pulmonary hypertension Up to 5% of patients after a PE May result in right ventricular failure

26. C/O right leg swelling of 2 days duration. Painful and getting worse A 24 year old man who works as university employee. He is previously healthy. ROS was within normal Denies trauma, recent illness, recent surgery. He was in Chicago for 3 weeks and came 1 week ago. He smokes 1 ppd for 5 years Not taking any medication. His brother died suddenly at age of 28 years, diagnosis was not known. Warm, swollen, red leg from calf to mid thigh Pitting edema and tender leg Chest and hear exam were normal WBC 8,000, Albumin 40 gm, Plts 160,000

27. Questions What is the likely diagnosis? What are the risks for this problem? What is the pathophysiology? How to confirm the diagnosis? What is the appropriate treatment? Is this problem preventable?

28. Deep Vein Thrombosis Cellulitis Ruptured Baker’s cyst Hematoma Musculoskeletal injury Venous stasis

29. DVT – Clinical Presentation Unilateral leg swelling Leg pain/tenderness - may increase with walking, standing, or exertion Warmth in the leg Bluish or reddish skin discoloration

30. Virchow’s Triad of Thrombosis

31. Risk factors for Deep Vein Thrombosis History of DVT/PE Age > 40 Prolonged immobility Stroke Hear Failure Recent surgery Trauma Fractures Venous catheters Nephrotic Syndrome Venous compression Pregnancy Recent delivery Caesarean section Obesity Estrogen Therapy (OCP) Vasculitis, IBD, SLE Cancer Acquired thrombophilia Varicose veins

32. Thrombophilia Young patients Unprovoked DVT or PE Recurrent VTE Strong family history of VTE Autosomal dominant

33. Thrombophilia Factor V Leiden (Activated protein C resistance) Most common Prothrombin gene mutation G20210A Hyperhomocysteinemia Anticardiolipin antibodies or Lupus anticoagulant Protein C deficiency Protein S deficiency Antithrombin deficiency Behçet disease

34. Venous Thrombosis After Long Flights “Long-haul flights of 8 hours and longer double the risk for isolated calf muscle venous thrombosis in patients with other risk factors. “

35. D-DIMERCross-linked Fibrin-degradation products Increased in the presence of active thrombosis Highly sensitive, but nonspecific Elevated in pregnancy, inflammation, advanced age, trauma, post-op, cancer High negative predictive value

36. ULTRASOUND (Compression and/or Doppler) Quick and available Non-invasive Pregnant patients Operator dependent Cannot be used to rule out PE

37. Post Thrombotic Syndrome Late complication of DVT The most common Occurring in up to two-thirds of patients Signs and symptoms are Pain, edema Hyperpigmentation Skin ulceration Severe manifestations occur in 7–23% Ulceration and 4–6%

38. Treatment

39. VTE - Treatment Without treatment, PE associated mortality of ~30% The result of recurrent embolism Accurate Dx. followed by effective Rx results in significant decrease in mortality ~ (2-8%) Quick and accurate Diagnosis & proper initial and long-term therapy is essential

40. VTE - Treatment Supportive Oxygen Analgesics IV fluids Hospital ward vs. ICU Anticoagulation Inferior vena cava (IVC) filter

41. VTE – Anticoagulation Rx. Immediate IV unfractionated heparin Bolus : 80 IU/Kg Drip :18 IU/Kg/hour Guided by aPTT SC Low Molecular Weight Heparin (LMH) Enoxaparin, Tinzaparin, Deltaparin, … No need to measure aPTT Weight based fixed dose

42. VTE - Anticoagulation Long-Term Therapy Oral warfarin Starts on day 1 Monitor PT and INR Targeted INR is 2-3

44. Prevention

45. Risk factors for Venous Thromboembolism History of DVT/PE Age > 40 Prolonged immobility Stroke Hear Failure Recent surgery Trauma Fractures Venous catheters Nephrotic Syndrome Venous compression Pregnancy Recent delivery Caesarean section Obesity Estrogen Therapy (OCP) Vasculitis, IBD, SLE Cancer Acquired thrombophilia Varicose veins

46. Prevention Early mobilization and leg exercise Adequate hydration Mechanical devices Elastic Stockings Graduated elastic compression stockings (GECS) Intermittent pneumatic compression (IPC) devices Heparins – subcutaneously Unfractionated Low molecular weight

47. VTE Prevention

48. Any Question!