Lecture 2: Cardiopulm Module 2

PT 512 Lecture Overview

• Module 2, Lecture 2 (Part 1): VTE CPG Review

• Date: 2/26/25

Muddiest Points from Previous Lecture

• Varicose Veins:

  • Concerns if exercise will exacerbate condition.

  • Duration before becoming problematic.

  • Not a source of embolism.

  • Explaining mobilization safety in patients with PAD (Peripheral Arterial Disease).

  • Exercise is not contraindicated even when PAD pain is ischemia-related.

Lecture Objectives

1. Define DVT (Deep Vein Thrombosis), VTE (Venous Thromboembolism), and PE (Pulmonary Embolism).

2. Identify risk factors associated with VTE and PE development.

3. Differentiate the screening tools for diagnosing DVT, VTE, and PE.

4. Discuss appropriate responses when a physical therapist suspects DVT or PE.

5. Outline mobilization guidelines for patients with VTE and PE.

6. Review medical interventions for DVT, VTE, and PE, and their impact on physical therapy.

7. Identify challenges faced by physical therapists in managing patients with VTE and PE in various settings.

Terminology in Vascular Conditions

• Thrombus: Blood clot.

• Phlebitis: Inflammation of veins that increases thrombus risk.

• Thrombophlebitis: Phlebitis accompanied by thrombus formation.

• Embolism: Movement of a clot from its original site.

• DVT: Formation of a thrombus in a deep vein.

• VTE: Presence of thrombus (DVT) and/or embolism.

• PE: Thrombus that has traveled to the pulmonary vasculature.

Definition of Venous Thromboembolism

• VTE Description: Clot formation in a vein, either as DVT primarily in lower extremity or as PE.

  • Serious yet preventable condition.

  • Occurrence: 1-2/1000 annually in the U.S.

  • Mortality rate for PE: 4.9% within 30 days of diagnosis.

Pathophysiology of Venous Thromboembolism

• Injury to blood vessels triggers hypercoagulation cascade from:

  • Surgery.

  • Traumatic injuries.

  • Venous stasis.

  • Venous damage and hypercoagulability.

• Risk persists for 5-6 weeks post-injury.

• Factors complicating the situation: decreased mobility, dehydration from medications, and positioning.

  • 45-80% of VTE occur post-discharge from a hospital.

Types of Venous Thrombosis

Superficial Venous Thrombosis

• Symptoms:

  • Ache, tenderness, redness, warmth.

  • Palpable hardened core.

  • No edema.

Deep Vein Thrombosis (DVT)

• Symptoms:

  • Pain, tenderness, discoloration, warmth.

  • Usually not palpable.

  • Edema present.

Signs and Symptoms of Venous Thromboembolism

• Common Signs:

  • Pitting edema, swelling, warmth, redness, discoloration of veins.

• Symptoms:

  • Local pain, tenderness.

  • If PE occurs: pleuritic chest pain, tachypnea, cough, syncope.

Classification of Pitting Edema

• Grading of Edema:

  • 1+: Barely perceptible depression.

  • 2+: Easily identifiable depression, rebounds within 15 seconds.

  • 3+: Rebounds within 15-30 seconds.

  • 4+: Rebounds after more than 30 seconds.

Long-term Risks of Venous Thromboembolism

• Patients may develop:

  • Post-Thrombotic Syndrome (PTS):

    • Affects 20-50% of LE DVT patients.

    • Causes permanent valve damage, resulting in venous hypertension.

    • Symptoms include chronic pain, edema, limb heaviness, and potential leg ulcers.

  • Chronic Thromboembolic Pulmonary Hypertension (CTEPH):

    • Prolonged obstruction of pulmonary arteries due to thrombi.

    • Leads to chronic inflammation, fibrosis, and hypertension of pulmonary tissue.

    • Symptoms: shortness of breath, fatigue, leg edema, dizziness, fainting, palpitations.

Medical Interventions for VTE

Pharmacological Approaches

• Thrombolytics: Medications to dissolve clots.

• Anticoagulants: Medications to prevent new clots and stop the growth of existing ones:

  • Major concern: potential bleeding, especially in those with high fall risk.

• Surgical Interventions:

  • Embolectomy, Vena Cava Filter, catheter-directed thrombolysis.

Physical Therapy Interventions

• Preventative Actions:

  • Early mobility, hydration, and patient education.

• Guidance:

  • Safe mobility after therapeutic anticoagulation.

• Diagnosis: Prior DVT history correlates with increased future risk.

Assessment for VTE in Physical Therapy

• Risk Assessment:

  • Use of the Padua Prediction Score to evaluate VTE risk, particularly in immobilized patients.

• Signs of DVT or PE:

  • Identifying symptoms, using Wells criteria for likelihood assessment.

Wells Criteria for DVT and PE Assessment

• DVT Criteria:

  • Total score calculated based on 10 clinical criteria (e.g., active cancer, leg swelling).

• PE Criteria: Helps to establish likelihood in symptomatic patients.

Conclusion and Further Reading

• Emphasis on the role of physical therapists in managing patients at risk for VTE: promote mobility and address prevention strategies.

• Refer to the Essential Clinical Practice Guidelines by APTA for comprehensive guidance on VTE management.

• Ensure evaluations and interventions are in line with pharmacological management to avoid complications.