Venous diseases and pulmonary embolism

risk factors VTE

surgery, trauma, bed rest, pregnancy, estrogen therap, thrombophilia

clinical features dvt

pain + swell in one leg, red + warm

tender deep veins and dilated sup. veins

Sign for dtv

Homans sign- calf pain at dorsiflexion

phlegmasia cerulea dolens

Severe case of dvt

First line imaging for dvt

venous US

Clinical pic thrombophlebitis

Inflammation signs over tract of superficial vein, palpable cord

clinical features PE

pleuritic chest pain, dyspnea, tachypnea + tachycardia

crackles, pleural rub

syncope, shock, MI

ECG PE

deep S wave in lead I, Q wave in III, inverted T wave in III = S1Q3T3

biomarkers in PE

bnp, probnp

risk scoring vte

wells score

for dvt - cancer, immobilization, tender along deep v, entire leg swollen, calf >3cm swollen, pitting edema, collaterals, history dvt

for pe - clinical pic dvt, tachy, immobilization, history, hemoptysis, malignancy

investigations vte

d dimer, us of deep v system, CTPA

timescaler of investigation

<24h, give anticoag

management VTE

anticoag

• acute (days) - parenteral LMWH or IV UFH, + warfarin, DOACs

• maintenance (3m) - warfarin, DOACs

• long-term

which doacs can be used alone from the outset

apixaban and rivaroxaban

treatment vte in pregnancy

LMWH

treatment vte in breastfeeding

warfarin, lmwh

treatment vte in cancer

LMWH

indications thrombolysis in vte

massive pe w/ shock → IV

treatment massive PE + COed thrombolysis

surgical emolectomy

treatment VTE + COed anticoag

ivc filters

Risk scores for prophylaxis in dtv

Padua, caprini,

complications

cancer-associated thrombosis (Trousseau)

post-thrombotic syndrome

pul htb

when to test for heritable thrombophilias

• unprovoked vte

• vte <50

• wanting pregnancy

• unusual site thromboses

diagnosis antiphospholipid syndrome

vte or a. thrombosis <50, unusual site thrombosis, recurrent episodes v thrombosis, pregnancy related morbidity, prolonged APTT

prevention vte

lmwh in hospital admission, low dose DOACs

use UFH

high risk settings, subcutaneous injections (short half life)

when is lmwh preferred to oral anticoags

pregnant, cancer-associated thrombosis

prophylaxis in hospital admission

heparin induced thrombocytopenia

a few days after heparin → IgG atb to heparin, increases risk thrombosis → use danaparoid (heparinoid)

how is effect of warfarin measured

inr

DOACs COs

mechanical valves, mitral stenosis, pregnancy

Dvt treatment

Initial - parenteral then VKA OR DOACs

Long term - VKA or DOACs

Types of dvt

Ascending, descending, trans-fascial (from saphenous)

What treatment is preferred in dvt treatment + CKD

UFH

Indications thrombolysis in dvt treatment

Symptomatic iliofemoral DVT

– Symptoms of less than 14 days duration

– Good functional status

– A life expectancy of 1 year or more

– Low risk of bleeding