Deep Vein Thrombosis

DEEP VEIN THROMBOSIS
DEEP VEIN THROMBOSIS What you should know
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
PARACLINICAL EXAMINATIONS
DIFFERENTIAL DIAGNOSIS
TREATMENT
COMPLICATIONS
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
DEFINITION: - thrombi at the level of deep veins of the leg or even abdominal (including inferior cava vein, portal vein)
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
Virchows triad - blood stasis - parietal venous lesion (endothelial damage) - hypercoagulability
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
MORPHOPATHOLOGY
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
CLINICS
Asymptomatic Unilateral edema Leg pain and tenderness Phlegmatia cerulea dolens-cyanotic from
massive iliofemural venous obstruction
Phlegmatia alba dolens white from massive

iliofemural+arterial compression/spasm
CLINICS
Homanss sign dorsiflexion Lowenbergs sign tensiometer 60Hg Ramirezs sign Liskers sign veins from bone. Louvels sign caugh Mikaeliss sign <38,5 AB/frison Mahlers sign FC.
SUPERFICIAL LEG THROMBOSIS .

Venous distension Proeminence of subcutaneous veins Palpable, indurated cord-like, tender subcutaneous venous segment extension
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
D-dimer
Fibrin degradation product Elevated in any madical condition with clots:
Trauma Recent surgery Hemorrhage Cancer Sepsis
Low specifity for DVT only to rule out DVT, not co confirm
LAB TESTS in young patients.

. . . . . .
LAB TESTS in young patients

Antithrombin III deficiency Protein C deficiency Protein S deficiency Prothrombin 20210A mutation Factor V Leiden
Homocisteine Antiphospholipidic syndrome

Lupus anticoagulant Anticardiolipine antibodies
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
PARACLINICAL EXAMINATION
Ultrasonography MRI CT Venogram
CT venogram
For suspected iliac vein thrombosis For suspected IVC thrombosis
MRI
for suspected iliofemoral DVT, IVC, SVC. When venography is contraindicated Iodine allergy, renal failure
VENOGRAPHY
Obese patients with important edema Non-invasive evaluation-not clear
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
Acute limb ischemia Artritis Limphangitis Celulitis Hematoma Limphedema Baker chist Post-trombotic sindrome, varicose veins.
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
DVT PREVENTION
DVT TREATMENT.
PHARMACOLOGICAL INTERVENTIONAL SURGICAL
PHARMACOLOGICAL
ANTICOAGULANT HEPARINE LMWH FONDAPARINUX
WARFARIN NEW: DABIGATRAN
PHARMACOLOGICAL
HEPARINE
bolus 80U/kg 18 U/kg/hour APTT 2-3
LMWH
Same eficacity as Heparine 1 mg/kg x2/day
FONDAPARINUX
Same eficacity as Heparine 7,5 mg 5 mg<50kg 10 mg>100kg
PHARMACOLOGICAL
At least 5 days + vitamin K antagonist: Warfarin Until INR >=2 for 24 hours.
WARFARIN -initial transient hypercoagulable state
WARFARIN
II, VII, IX, X, protC, protS. X, II t1/2 24-72 hours.
Agravation with Warfarin
WARFARIN-duration
Calf DVT 3 months Proximal DVT- 6 months Upper extremity DVT- 3 months Recurrent episodes- 1 year.
PHARMACOLOGICAL
THROMBOLYSIS:
1. Massive iliofemoral DVT
2. Young patients with phlegmatia alba
dolens (limb ischemia)
INTERVENTIONAL
IVC filter: To block any clots which might embolize
Contraindications to anticoagulants Severe hemorrhagic complications to anticoagulants Failure to anticoagulant therapy (recurrent DVT, PE)
SURGERY
Massive ileofemoral DVT (phlegmatia cerulea dolens)
+contraindications to thrombolysis The clot can be removed
TREATMENT
Compression stockings
Reduces leg edema Assist the calf muscle pump From the first day of treatment
Ambulation:
day 2 after initiation of anticoagulation therapy + compression
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
COMPLICATIONS
Post thrombotic syndrome Pulmonary embolism
POST THROMBOTIC SYNDROME
POSTTHROMBOTIC SYNDROME AND CHRONIC INSUFFICIENCY
Varicose veins Abnormal pigmentation Venous ulcerations
Which of the following are clinical findins in deep vein thrombosis?

PR segment depression Unilateral edema Phlegmatia cerulea dolens Palpable, indurated cord-like, tender subcutaneous venous segment Homanss sign pain at dorsiflexion
PULMONARY EMBOLISM
Carto + semne EKG
CASE PRESENTATION
ACUTA DYSPNEEA
ANAMNESYS
Male, 67 ani, Sanpaul jud. Cluj
Dyspneea
Dry cough
ANAMNESYS
5 days ago Dyspneea: brutal, rapid onset during effort
Generalist- Sanpaul
Ambulance-Cluj-Emergency Department
ANTECEDENTS
HTA-2007 max 160/100 Hypercolesterolemia-2007
MEDICATIONS
Prestarium 5 mg 1-0-0 tb/zi. Simvastatin 20mg 0-0-1 tb/zi.
CLINICAL FINDINGS
T=37,4 C; pale, mild finger cianosis;
PHYSICAL EXAMINATION
Respiratory: no rales
C-V: tachycardia 120/min, nu murmurs, TA=135/95mmHg. Hepatomegaly 3cm , +jugular distension.
CLINICAL INTERPRETATION
.
.
.
.
CLINICAL INTERPRETATION
CARDIAC TAMPONADE?
PULMONARY EMBOLISM? METABOLIC DYSPNEEA ACIDOSIS ? ANEMIA ?
LAB TESTS
I line tests
CBC
Second line tests

Thrombophylia tests
Biochemistry
Coagulation
ABG
Ddimers
LAB TESTS
Gli=92mg/dl Col=157mg/dl Tgl=56mg/dl Ac. Uric=7,2 mg/dl Na=144mEq/l K=3,8mEq/l Ca=4,9 azot=33mg/dl creat=1,1mg/dl ASAT=15U/l ALAT=10U/l LDH=411U/l Bilirubina=0,5mg/dl TQ=14,6 INR=1,21 Troponina I <0,2g/ml CPK=74U/l
ESR=14-37 Hb= 14,5 g/dl L= 14800/mm3 Tr= 131000/mm3
LAB TESTS
I line tests
CBC
Second line tests

Thrombophylia tests
Biochemistry
Coagulation
ABG
Ddimers
GAZE SANGUINE .
SaO2=87,5% paO2=51,4 paCO2=29,3 pH=7,495 HCO3=18
LAB TESTS
I line tests
CBC
Second line tests

Thrombophylia tests
Biochemistry
Coagulation
ABG
Ddimers
D dimers +2g/ml
(V.N. <0,2g/ml)
ANALIZE DE LABORATOR
D dimeri +2g/ml
Troponine I <0,2g/ml BNP=74U/l
First line
EKG
Second line
Venous ultrasound
Rx
Ecocardiography
Pulmonary scintigraphy
CT angiogram IRM
Amgiography
First line Second line
Venous ultrasound
EKG
Rx Ecocardiography
CT angiogram IRM
Amgiography
EKG
EKG
EKG
EKG
EKG
EKG
First line
EKG
Second line
Venous ultrasound
Rx
Ecocardiography
CT angiogram IRM
Amgiography
RX PULMONAR
First line
EKG
Second line
Venous ultrasound
Rx
CT angiogram IRM
Ecocardiography
Angiography
ECOCARDIOGRAPHY
RV=31
IVS TR - paradoxical movement -PAP=40-45mmHg
First line
EKG
Second line
Rx
Ecocardiography
Venous ultrasound Pulmonary scintigraphy CT angiogram IRM Angiography
LIMB ULTRASOUND
First line
EKG
Second line
Venous ultrasound
Rx
Ecocardiography
Pulmonary
scintigraphy
CT angiogram IRM Angiography
PULMONARY SCINTIGRAPHY
DIAGNOSYS
MODERATE BILATERAL PULMONARY THROMBOEMBOLISM. DEEP VEIN THROMBOSIS RIGHT LEG
ARTERIAL HYPERTENSION GRADE 2 (ESC).
TREATMENT
Oxygen
Clexane 2x80 mg/zi Omeran 20mg/zi Cefort 1 grx2/zi Codeine phosphate tbx2/zi Atacand 16 mg dimineata Simvastatin 20mg/zi
EVOLUTION
EKG
EKG
EKG
EKG
EKG -at 2 months
CHEST X-ray
CHEST X-ray
PULMONARY EMBOLISM
What you should know
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
PULMONARY EMBOLISM
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
PULMONARY EMBOLISM
Complication of DVT Obstruction of one or more branches of the pulmonary artery through an embolus migrating from a deep vein thrombosis
PULMONARY EMBOLISM
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
PULMONARY EMBOLISM
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
PULMONARY EMBOLISM
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
PULMONARY EMBOLISM
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
PULMONARY EMBOLISM
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
PULMONARY EMBOLISM
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
CLINICS
Acute dyspneea with normal pulmonary examination
CLINICS
Dyspneea with normal lungs severe chest pain SBP (+/- cardiogenic shock) cyanosis (respiratory failure) tachycardia later: right sided heart failure
CLINICS
Massive pulmonary embolism Submassive PE Low risk PE
PULMONARY EMBOLISM
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
PULMONARY EMBOLISM
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
LAB TESTS
Ist line tests
CBC
Second line tests

Thrombophylia tests
Biochemistry
Coagulation
ABG
Ddimers
LAB TESTS
I line tests
CBC
Second line tests

Thrombophylia tests
Biochemistry
Coagulation
ABG
Ddimers
LAB TESTS
I line tests
CBC
Second line tests

Thrombophylia tests
Biochemistry
Coagulation
ABG
Ddimers
D-dimers
D-dimers
PULMONARY EMBOLISM
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
PULMONARY EMBOLISM
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
First line
EKG
Second line
Venous ultrasound
Rx
Ecocardiography
CT angiogram IRM
Amgiography
First line Second line
Venous ultrasound
EKG
Rx Ecocardiography
CT angiogram IRM
Amgiography
EKG
clockwise rotation S1Q3. Right axis deviation Ischemic signs Conduction troubles:RBBB Arrythmias: ST, ExA, ExV, AF, AfT.
First line
EKG
Second line
Venous ultrasound
Rx
Ecocardiography
CT angiogram IRM
Amgiography
First line
EKG
Second line
Venous ultrasound
Rx
Ecocardiography
CT angiogram IRM
Amgiography
CHEST X-Ray
Westermark sign Atelectasis Small pleural effusion Elevated diaphragm Triangular radioopacity with the base towards the pleura
First line
EKG
Second line
Venous ultrasound
Rx
CT angiogram IRM
Ecocardiography
Angiography
First line
EKG
Second line
Rx
Ecocardiography
Venous ultrasound Pulmonary scintigraphy CT angiogram IRM Angiography
First line
EKG
Second line
Venous ultrasound
Rx
Ecocardiography
Pulmonary
scintigraphy
First line
EKG
Second line
Venous ultrasound
Rx
Ecocardiography
First line
EKG
Second line
Venous ultrasound
Rx
Ecocardiography
CT angiogram IRM
Angiography
PULMONARY EMBOLISM
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
PULMONARY EMBOLISM
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
Myocardial ischemia: RV infarction
Pericarditis: cardiac tamponade Anemia Metabolic acidosis Cardiogenic shock Aortid dissection COPD Penumothorax Cor pulmonale Musculoskeletal pain
PULMONARY EMBOLISM
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
PULMONARY EMBOLISM
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
TREATMENT OF PE
Pharmacological Interventional Surgical
TREATMENT OF NON-MASSIVE PULMONARY EMBOLISM
Pharmacological
HEPARINE
LMWH
FONDAPARINUX
Pharmacological
HEPARINE: 80 U/kg or 5000 bolus
infusion: 18 U/kg/h or 1300 U/kg APTT Renal impairment CrCl<20-30ml/min
LMWH no monitoring
FONDAPARINUX anti-X a
aPTT=activated partial thromboplastin time, with therapeutic range-60-80 seconds.
LMWH
FONDAPARINUX=anticoagulant that specifically inhibits activated

factor X.
WARFARIN
Vit K antagonist After 5 days of Heparine/LMWH or Fondaparinux 2 consecutive days of INR 2-3
INR-2-3.
DURATION OF TREATMENT
Calf DVT 3 months Proximal DVT- 6 months Upper extremity DVT- 3 months Pulmonary embolism- 6 months Pulmonary embolism+cancer -lifelong Recurrent PE lifelong
Pulmonary embolism + AT III deficiency/Leiden mutation, prot C, prot S deficiency life-long.
TREATMENT OF MASSIVE PULMONARY EMBOLISM
THROMBOLYSIS
Streptokinase Urokinase Alteplase Reteplase Tenecteplase Heparine+Thrombolysis+Volume 500-1000ml
THROMBOLYSIS
Streptokinase 1,5 mil U/2h Urokinase 3 milU/2 h Alteplase 100mg/2h Reteplase 10U+10U (30 min) Tenecteplase 30 mg bolus50mg Heparine+Thrombolysis+Volume 500-1000ml 14 days
INTERVENTIONAL
INTERVENTIONAL
IVC FILTERS:
1. CI to anticoagulants
2. Massive PE who survived recurrent may
be fatal. 3. Recurrent venous thromboembolism under anticoagulants
SURGICAL
Pulmonary endarterectomy
PULMONARY EMBOLISM
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
PULMONARY EMBOLISM
DEFINITION
ETIOLOGY
MORPHOPATHOLOGY
CLINICS
LAB TESTS
TREATMENT
COMPLICATIONS
COMPLICATIONS
Sudden cardiac death Shoc PEA Atrial/Ventricular arrythmias Secondary PAH Cor pulmonale Severe hypoxemia Right-to-left intracardiac shunt Lung infarction
In case of a pulmonary embolism, which are the possible complications ?

Ventricular septal defect Sudden cardiac death Secondary pulmonary arterial hypertension Pneumothorax Renal carcinoma
The pharmacological treatment of non massive pulmonary embolism can be made with:
Heparine Enoxaparine Streptokinase Vitamin K agonists (Fitomenadione) Surgery

Deep Vein Thrombosis

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Deep Vein Thrombosis

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DEEP VEIN THROMBOSIS

DEEP VEIN THROMBOSIS What you should know

DEEP VEIN THROMBOSIS What you should know

DEEP VEIN THROMBOSIS What you should know

DEEP VEIN THROMBOSIS What you should know

DEEP VEIN THROMBOSIS What you should know

DEEP VEIN THROMBOSIS What you should know

DEEP VEIN THROMBOSIS What you should know

DEEP VEIN THROMBOSIS What you should know

Phlegmatia alba dolens white from massive

SUPERFICIAL LEG THROMBOSIS .

DEEP VEIN THROMBOSIS What you should know

DEEP VEIN THROMBOSIS What you should know

LAB TESTS in young patients.

LAB TESTS in young patients

Homocisteine Antiphospholipidic syndrome

DEEP VEIN THROMBOSIS What you should know

DEEP VEIN THROMBOSIS What you should know

DEEP VEIN THROMBOSIS What you should know

DEEP VEIN THROMBOSIS What you should know

DEEP VEIN THROMBOSIS What you should know

DEEP VEIN THROMBOSIS What you should know

WARFARIN NEW: DABIGATRAN

WARFARIN -initial transient hypercoagulable state

Agravation with Warfarin

2. Young patients with phlegmatia alba

dolens (limb ischemia)

DEEP VEIN THROMBOSIS What you should know

DEEP VEIN THROMBOSIS What you should know

POST THROMBOTIC SYNDROME

POSTTHROMBOTIC SYNDROME AND CHRONIC INSUFFICIENCY

Varicose veins Abnormal pigmentation Venous ulcerations

Which of the following are clinical findins in deep vein thrombosis?

Carto + semne EKG

T=37,4 C; pale, mild finger cianosis;

C-V: tachycardia 120/min, nu murmurs, TA=135/95mmHg. Hepatomegaly 3cm , +jugular distension.

Second line tests

ESR=14-37 Hb= 14,5 g/dl L= 14800/mm3 Tr= 131000/mm3

Second line tests

SaO2=87,5% paO2=51,4 paCO2=29,3 pH=7,495 HCO3=18

Second line tests

Troponine I <0,2g/ml BNP=74U/l

Venous ultrasound Pulmonary scintigraphy CT angiogram IRM Angiography

ARTERIAL HYPERTENSION GRADE 2 (ESC).

EKG -at 2 months

Second line tests

Second line tests

Second line tests

Venous ultrasound Pulmonary scintigraphy CT angiogram IRM Angiography

CT angiogram IRM Angiography

TREATMENT OF NON-MASSIVE PULMONARY EMBOLISM

aPTT=activated partial thromboplastin time, with therapeutic range-60-80 seconds.

FONDAPARINUX=anticoagulant that specifically inhibits activated

TREATMENT OF MASSIVE PULMONARY EMBOLISM

2. Massive PE who survived recurrent may

be fatal. 3. Recurrent venous thromboembolism under anticoagulants

In case of a pulmonary embolism, which are the possible complications ?

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