DVT ppt.pptx

DVT

1. Deep Vein Thrombosis Dr Mahmood Emergency Medicine Resident MEM

2. Case 1 A 67 old male patient presented with c/o painful swelling of left lower limb since 5-6 days h/o trauma to left lower limb 3 days back Past history: nil No H/o: chest pain, SOB General examination: -PR: 82/ mins -RR:20/ mins -Bp: 130/90mmhg -Sp02: 98% on RA Systemic examination: -RS: bilateral air entry -CVS: s1+, s2+ -P/A: soft. BS+ L/E : swelling of left lower limb foot to thigh, tenderness +, movements+, peripheral pulses+

3. Labs CBP : normal , TLC : 17,000 Bleeding time and clotting time : normal 2D-echo: - no RWMA, -good LV function , -IVC collapsing Color Doppler of venous system of left lower limb performed -Impression: intramural echogenic contents with absent color flow uptake in distal SFV and popliteal vein s/o DVT

4. Case A 45 years old male patient presented with complaints of right lower limb painful swelling since 4 days. Sudden onset, Increasing gradually Sever cramping pain in calf and thigh increased on walking and movement of the limb h/o l eft sided nephrectomy 5 days back for left side renal cell carcinoma (RCC) h/o chronic tobacco chewing No h/o of chest pan , SOB , abdomen pain No family history of VTE

5. General examination: -PR: 92/ mins -Bp: 140/90mmhg -RR:20/ mins -Sp02: 98% on RA Systemic examination: -RS: bilateral air entry -CVS: s1+, s2+ -P/A: soft. BS+, scar of nephrectomy is seen over left lumbar L/E : Swelling and redness over right lower limb from foot to thigh, no dilated , engorged veins , skin is stretched and shiny

6. Duplex ultrasound: Impression: Common femoral ,deep femoral, popliteal and posterior tibial vein show echogenic thrombus and absent flow . s/o DVT 2D-echo: -no RWMA, -good LV function , -IVC collapsing

7. Surgical Management: - Debridment of wound + IVC filter placement done Medical management : - Tab ciplox (ciprofloxacin) 500 mg bd -Tab ultracet ( paracetamol + tramadol ) 1 tab bd -Tab bevon tab od -Tab pradaxa ( dabigatran )150mg bd x 1month -Tab dolo ( paracetamol ) 650 tid Advise: - Left lower limb elevation -High protein diet

8. Contents Introduction Etiology Risk factors Clinical features Complications Diagnostic procedures Management Prevention Differentials References

9. Deep vein thrombosis Deep vein thrombosis (DVT) is the formation of a blood clot in a deep vein most commonly seen n the legs or in the arms

10. Provoked DVT: DVT where there is an identifiable risk factor that likely caused the DVT. Unprovoked DVT: DVT where there is no identifiable risk factor that likely caused the DVT

11. Etiology DVT usually originates in the lower extremity venous system, starting at the calf and progressing proximally to involve popliteal, femoral or iliac system 80-90% pulmonary emboli originates here

12. Pathophysiolgy An intimal defect often works as nidus for clot formation Initially a platelet aggregate develops, subsequently clotting factors through intrinsic and extrinsic pathway fibrin and red cells form a mesh until the lumen clot occludes the vein wall.

13. Venus stasis Age: incidence increase with advancing age Obesity: > BMI > is DVT Prolonged bed rest ( 4days or more) Lower limb fracture: a cast on the leg limb paralysis Extended travel (>4 hours)

14. Hypercoagulablity Acquired: Surgery and trauma are responsible for upto 40% of all thromboembolic disease Malignancy Hormonal therapy, OCP Pregnancy Nephrotic syndrome Antiphospholipid antibody syndrome SLE, IBD

15. Inherited : Factor V Leiden mutation Antithrombin deficiency Protein C, S deficiency Prothrombin 20210 gene variant Homocysteinemia

16. Endothelial injury Trauma Surgery Peripheral and central lines

17. Clinical features Calf pain or tenderness or both Swelling wit pitting edema Increase in local temperature Redness or discoloration Dilatation of superficial veins

18. Pitting edema grading

19. Less frequent manifestations of DVT includes Phlegmasia cerulea dolens Phlegmasia alba dolens Venous gangrene

20. Phlegmasia cerulea dolens Extensive DVT of the major axial deep venous channels of the lower extremity with relative sparing if collateral veins The leg becomes blue in color , swollen and painful Which may result in venous gangrene.

21. Phlegmasia alba dolens When the thrombosis extends to the collateral veins, massive fluid sequestration and significant edema a/k/a Milk leg or white leg The leg is pale and cold, secondary to arterial insufficiency, Extremely tender

22. Signs Homan’s sign: Pain in the calf region or knee with forced dorsiflexion

23. Moses / Bancroft’s sign: Gentle squeezing of the lower part of the calf from side to side causes sever pain Lowenberg sign: - Pain is elicited rapidly when a blood pressure cuff is placed and around the calf and inflated to 80mmhg

24. Diagnostic studies Clinical examination alone is able to confirm only 20-30%cases of DVT Blood test : D- Dimer test Coagulation profile Routine hematological investigation Imaging studies ECG and 2D echo

25. D- dimer : D- dimer is a degradation product of fibrin cross-linking And elevated D- dimer level can occur when blood clots are being formed. It can also be elevated in other conditions unrelated to DVT (cancer, pregnancy, recent surgery) The cutoff value for normal D- dimer is <500mcg/L

26. Imaging studies Non invasive: Duplex ultrasound Plethysmography MRI techniques

27. Invasive: Venography Radio labeled fibrinogen

28. Management

29. Surgical management Indications: When anticoagulant therapy is ineffective Unsafe Contraindicated The major surgical procedures for DVT are clot removal and partial interruption of the inferior vena cava to prevent pulmonary embolism.

30. Inferior vena cave filter: it’s a type of vascular filter into inferior vena cava to prevent life- thraetening pulmonary embolism. Indication: Pulmonary embolism with contraindication to anticoagulation. Recurrent pulmonary embolism despite adequate anticoagulation.

31. Complications Pulmonary embolism (PE ): PE is a potentially life-threatening complication associated with DVT. Sudden shortness of breath, chest pain while inhaling and coughing up blood may occur with PE. Post- phlebitic syndrome: which manifest as leg pain and swelling, skin discoloration and skin sores. Treatment complication: Bleeding ( hemorrhages). Recurrent DVT Chronic venous insufficiency Paradoxic emboli

32. Life style modification Do regular walking Limiting the amount of time you spend sitting Exercising daily, mainly walking, swimming or other activities that promote good blood circulation. Avoid wearing tight- fitting clothes for extended periods. Drinking lots of fluids

33. Consuming foods that acts as natural blood thinners to reduce the risk of developing blood clots, such as vitamin–E, ginger, cayenne pepper, garlic, turmeric and cinnamon Wearing Elastic compression stockings Lower your blood pressure with dietary changes, like reducing your salt and sugar intake. Lose weight if overweight Quit smoking

34. Differentials Muscular tear Rupture of a Baker’s cyst Cellulites or other infection Thrombophlebitis Tumors Connective tissue disorders

35. References Tintinallis emergency medicine Rosens emergency medicine Dutton. Orthopedic examination, evaluation and intervention Belly and love surery Medscape

36. Thank you