Download Deep Venous Thrombosis & Pulmonary Embolism

Pulmonary Embolism &
DVT
Introduction
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Pathophysiology
Risk Factors
Symptoms
Lab Findings
Radiology Findings
Treatment
Prevention
Pathophysiology
Dislodgement of a blood clot:
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Lower Extremities: 65% to 90%
Pelvic venous system
Renal venous system
Upper Extremity
Right Heart
Risk Factors for PE and DVT
• Immobilization
• Surgery within the last 3
months
• Stroke
• History of venous
thromboembolism
• Malignancy
• Preexisting respiratory
disease
• Chronic Heart Disease
• Age >60
• Surgery requiring >30mins of
anesthesia
• Recent travel (past
2weeks, >4 hours)
• Varicose veins
• Superficial vein thrombosis
• Central VV
catheter/port/pacemaker
Additional RF in Women:
• Obesity BMI >/=29
• Heavy smoking
(>25cigs/day)
• Hypertension
• Pregnancy
Well’s Criteria
Clinical Signs and Symptoms of DVT?
+3
(Calf tenderness, swelling >3cm, errythema, pitting
edema affected leg only)
PE Is #1 Diagnosis, or Equally Likely
+3
Heart Rate > 100
+1.5
Immobilization at least 3 days, or Surgery in the
Previous 4 weeks
+1.5
Previous, objectively diagnosed PE or DVT?
+1.5
Hemoptysis
+1
Malignancy w/ Rx within 6 mo, or palliative?
+1
>6:
2 to 6:
2 or less:
High Risk
Moderate Risk
Low
Adapted with permission from Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, 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;83:416-20.
P.E. and Malignancy
• A Presenting sign in:
– Pancreatic cancer
– Prostate cancer
• Late sign in:
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Breast cancer
Lung cancer
Uterine cancer
Brain cancer
Symptoms of P.E.
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Dyspnea
Pleuritic pain
Cough
Hemoptysis (blood tinged/streaked/ pure
blood)
Signs of P.E.
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Tachypnea
Rales
Tachycardia
Hypoxia
S4
Accentuated pulmonic component of S2
Fever: T <102 F
Signs in Massive P.E.
• “Massive PE”: hemodynamic instability
with SBP <90 or a drop in baseline SBP by
>/=40mmHg
• Signs as before PLUS:
– Acute right heart failure
• Elevated J.V.P.
• Right-sided S3
• Parasternal lift
P.E. & Leg Symptoms
• Most patients with P.E. do not have leg
symptoms at time of diagnosis
• Patients with leg symptoms may have
asymptomatic P.E.
Lab & Radiologic Findings in
P.E.
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ABG
BNP
Cardiac Enzymes: Troponin
D-dimer
EKG
CXR
Ultrasound
V/Q Scan
Angiography
Lab Findings in P.E.
(ABG)
• ABG:
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Hypoxemia
Hypocapnia (low CO2)
Respiratory Alkalosis
Massive PE: hypercapnia, mix resp and metabolic
acidosis (inc lactic acid)
– Patients with RA pulse ox readings <95% are at
increased risk of in-hospital complications, resp
failure, cardiogenic shock, death
Lab Findings in P.E. (BNP)
• BNP (beta natruretic peptide)
– Insensitive test
– Patient’s with PE have higher levels than pts without,
but not ALL patients with PE have high BNP
– Good prognostic value measure: if BNP >90
associated with adverse clinical outcomes (death,
CPR, mechanical vent, pressure support,
thrombolysis, embolectomy)
Lab Findings in P.E. (Troponin)
• Troponin
– High in 30-50% of pts with mod to large PE
– Prognostic value if combined pro-NT BNP
• Trop I >0.07 + NT-proBNP >600 = high 40 day
mortality
Lab Findings in P.E.
(D-dimer)
• D-dimer:
– Degredation product of fibrin
– >500 is abnormal
– Sensitivity: High, 95% of PE pts will be
positive
– Specificity: Low
– Negative Predictive Value: Excellent
S1Q3T3!!!
RAD
Right Atrial Enlargement
Lab Findings in P.E. (cont’d)
• EKG
– 2 Most Common finding on EKG:
• Nonspecific ST-segment and T-wave changes
• Sinus Tachycardia
– Historical abnormality suggestive of PE
• S1Q3T3
• Right ventricular strain
• New incomplete RBBB
Radiologic Findings in P.E.
GOLD STANDARD IN
DIAGNOSING PULMONARY
EMBOLISM?
PULMONARY ANGIOGRAM
Radiology Findings in P.E.
(cont’d)
• CXR:
– Normal
– Atelectasis and/or pulmonary parenchymal
abnormality
– Pleural Effusion
– Cardiomegally
What’s This???
Hampton’s Hump
How About This???
Westermark's Sign: an abrupt tapering of a vessel caused by
pulmonary thromboembolic obstruction.
This CXR shows enlargement of the left hilum accompanied by left
lung hyperlucency, indicating oligemia (Westermark's sign).
Radiology Findings in P.E.
(cont’d)
V/Q Scan:
• Results: High, Intermediate, Low Probability
• Best if combined with Clinical Probability
(PIOPED study):
– High Clinical Prob + High Prob VQ= 95% likelihood
of having a P.E.
– Low Clinical Prob + Low Prob VQ= 4% likelihood of
having a P.E.
Radiology Findings in P.E.
(cont’d)
Lower Extremity Ultrasounds
• If DVT found then treatment is same if
patient has a P.E.
• Disadvantage:
– If negative, patients with PE may be missed
– If false positive (3%), unnecessary
intervention
Radiology Findings in P.E.
(cont’d)
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CT Pulmonary Angiography (CT-PA)
Widely used
Institution dependent
Sensitivity (83%)
Specificity (96%): if negative, very low
likelihood that pt has P.E.
Radiology Findings in P.E.
(cont’d)
Pulmonary Angiogram
• Gold Standard
• Not easily accessible
• Radiologist dependent
Radiology Findings in P.E.
(cont’d)
Echocardiogram
• Increased Right Ventricle Size
• Decreased Right Ventricular Function
• Tricuspid Regurgitation
Rarely:
• RV thrombus
• Regional wall motion abnormalities that spare
the right ventricle apex (McConnell’s Sign)
Hypercoagulability Work Up
• No consensus on who to test
• Increased likelihood if:
– Age <50y/o without immediate identifiable risk factors
(idiopathic or provoked)
– Family history
– Recurrent clots
– If clot is in an unusual site (portal, hepatic, mesenteric,
cerebral)
– Unprovoked upper extremity clot (no catheter, no
surgeries)
– Patient’s with warfarin induced skin necrosis (they may
have protein C deficiency
Hypercoagulability Work Up
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Protein C/S deficiency
Factor V leiden deficiency
AntiThrombin III deficiency
Prothrombin 20210 mutation
Antiphospholipid antibody
High Homocysteine
Most Common Cause of
Congenital Hypercoagulablity
• Protein C resistance d/t Factor V leiden mutation
Treatment of P.E.
• Respiratory Support: Oxygen,
intubation
• Hemodynamic Support: IVF,
vasopressors
• Anticoagulation
• Thrombolysis
• IVC Filter
Anticoagulation
• Start during resuscitation phase itself
• If suspicion high, start emperic anticoagulation
• Evaluate patient for absolute contraindication
(i.e.: active bleeding)
Anticoagulation (cont’d)
• HEPARIN:
– Lovenox: if hemodynamically stable, no renal function
• 1mg/kg BID OR 1.5mg/kg QDay
– Heparin gtt: if hypotension, renal failure
• 80units/kg bolus then 18units/kg infusion
• Goal PTT1.5 to 2.5 times the upper limit of normal
• COUMADIN:
– Start once acute anticoagulation achieved
– Start with 5mg PO qday OR 10mg PO q day
– If start with 10mg then achieve therapeutic INR 1.4 days
sooner
– Complications and morbidity no different in 5mg or 10mg start
– Goal INR 2 to 3
Duration of Anticoagulation for
DVT or PE*
Event
Duration
Strength of
Recommendation
First Time event of
Reversible cause
(surgery/trauma)
At least 3 mos
A
First episode of
idiopathic VTE
At least 6 mos
A
Recurrent idiopathic
VTE or continuing risk
factor (e.g.,
thrombophilia, cancer)
At least 12 mos
B
Symptomatic isolated
calf-vein thrombosis
6 to 12 weeks
A
*From American College of Chest Physicians
Thrombolysis
• Considered once P.E. diagnosed
• If chosen, hold anticoagulation during
thrombolysis infusion, then resumed
• Associated with higher incidence of major
hemorrhage
• Indications: persistent hypotension, severe
hypoxemia, large perfusion defecs, right
ventricular dysfunction, free floating right
ventricular thrombus, paten foramen ovale
• Activase or streptokinase
IVC Filter
• Indication:
– Absolute contraindication to anticoagulation (i.e.
active bleeding)
– Recurrent PE during adequate anticoagulation
– Complication of anticoagulation (severe
bleeding)
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Pts with poor cardiopulmonary reserve
Recurrent P.E. will be fatal
Patient’s who have had embolectomy
Prophylaxis against P.E. in select patients
(malignancy)
Embolectomy
• Surgical or catheter
• Indication:
– Those who present severe enough to warrant
thrombolysis
– In those where thrombolysis is
contraindicated or fails
Questions?