Deep Vein Thrombosis / Pulmonary Embolism

Deep Vein Thrombosis

- Signs/Symptoms
- Edema most specific symptom
- Pain (occurs in approx half of affected patients but is not specific)
- Homans Sign pain in calf with forced dorsiflexion of the ankle
- Pratts Sign pain with compression of the calf
- Warmth over affected area
- Tenderness occurs in approx affected
- Discoloration of lower extremity quite variable; reddish purple from
venous engorgement and/or obstruction
- Risk Factors
- Virchows Triad
- Hypercoaguable state
- Immobilization
- Endothelial injury
- I AM CLOTTED
- Previous DVT
- Family History
- Pregnancy/Oral contraceptives
- Malignancy
- Trauma
- Obesity
- Diagnosis
- Wells Criteria (see handout)
- Ultrasound -- visualization
- D-dimer -- >500g/mL; sensitive (97%) but not specific (35%)
- Coagulation profile (PT/PTT/INR)
- Treatment (see handout)
- Acute Anti-coagulation therapy
- IV Unfractionated Heparin
- Immediate bolus of 80 mg/kg IV -> 18 mg/kg/hr
- check PTT Q6 until supra-therapeutic range (1.5-2.5)
- Enoxaparin
- 1mg/kg Q12 SubQ
- Continued Care
- Warfarin
- 10mg or 7.5mg loading dose PO Q24 for first 2-3 days
- Continue until supra therapeutic goal is reached (INR 2.5)
- Continue Heparin until target INR reached
- Maintain INR for 3 months
- Consider prophylactic IVC Filter placement (Greenfield)

Crozer Chester Medical Center

Pulmonary Embolism
- Sign/Symptoms
- Hemoptysis*
- Dyspenea*
- Pleuritic chest pain*
- Cough
- Tachypenea
- Risk Factors
- Travel of > 4hrs in past month
- Surgery w/in 3 mnths
- Smoking
- COPD
- Stroke, paresis, paralysis
- Diagnosis
- Wells Criteria (see handout)
- Pulmonary Angiography*
- Spiral CT
- V/Q Study
- CXR
- Treatment
- Thrombolytic Therapy
- Urokinase
- 4400 units/kg IV acutely over 10 mins; 4400 units/kg/hr
12hrs
- Streptokinase
- 1.5 million units IV Q1 hour
- Embolectomy
- Indications: Fibrolytic failure, massive PE
- Catheter or surgical
- IVC Filter (Greenfield)
- Supportive Care
- Compression stockings
- Daily ambulation
- Prevention
- Prophylactic therapy (mechanical or anti-coag therapy) in hospitalized pts

Sources:
1. Wells et al., Derivation of a simple clinical model to categorize patients
probability of pulmonary embolism: increasing the models utility with the
SimpliRED D-dimer. Thromb Haemost. 2000 Mar;83(3):416-20
2. Kesieme, E., C. Kesieme, N. Jebbin, E. Irekpita, and A. Dongo. Deep Vein
Thrombosis: a clinical review. Journal of Blood Medicine. 2011 (2) 59-69.
3. Falck-Ytter, Y., Francis, C., Johanson, N., Curley, C., Dahl, O., Schulman,S., Ortel,
T., Pauker, S., Colwell, C. Prevention of VTE in Orthopedic Surgery Patients.
Chest. 9th ed: American College of Chest Physicians. 141 / 2 / Feb, 2012
supplement
Crozer Chester Medical Center
4. Kline JA, Runyon MS. Pulmonary embolism and deep venous thrombosis. In:
Marx JA, Hockenberger RS, Walls RM, eds. Rosen's Emergency Medicine
Concepts and Clinical Practice. Vol 2. 6th ed. 1368-1382.
5. Stein PD, Beemath A, Matta F, Weg JG, Yusen RD, Hales CA, et al. Clinical
characteristics of patients with acute pulmonary embolism: data from
PIOPED II. Am J Med. Oct 2007;120(10):871-9.
6. Torbicki A, Perrier A, Konstantinides S, Agnelli G, Gali N, Pruszczyk P, et al.
Guidelines on the diagnosis and management of acute pulmonary embolism:
the Task Force for the Diagnosis and Management of Acute Pulmonary
Embolism of the European Society of Cardiology (ESC). Eur Heart J. Sep
2008;29(18):2276-315.

Crozer Chester Medical Center