Post on 02-Mar-2018
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Deep vein
thrombosis
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Semisolid coagulum within fowing blood invenous system
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Patient actorsAge
Obesity
Varicose veinsImmobility
Pregnancy Puerperium
High-dose oestrogen
therapyPrevious V! or P"
!hrombophilia
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iseaseSurgery# !rauma
$alignancy
Heart ailure%ecent $I
Paralysis o lowerlimb
Inection
Infammatory boweldisease
&ephrotic syndrome
Polycythaemia
Paraproteinaemia
P&H'eh(et)s disease
Homocystinaemia
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!hrombophiliaCongenital
e*ciency o anti-thrombin III# protein +
or protein S
Antiphospholipidantibody or lupusanticoagulant
,actor V eiden genedeect or activatedprotein + resistance
ys*brinogenaemias
Acquired
Antiphospholipidantibody or lupusanticoagulant
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+linical eaturesPain and swelling o
cal
%edness
"ngorged super*cialveins
cramp in the lower
cal that persists or
several days and
becomes moreuncomortable as time
progresses.
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Pittng edema
ilated veins
Sti/ cal !ender vein course
Homans sign
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+linical eaturesFeatures of PE
$assive - yspnea# syncope# hypotension#
cyanosissmall - situated distally near the pleura-
pleuritic pain# cough# or hemoptysis
0classic0 signs- tachycardia# low-grade ever#
nec1 vein distention# and an accentuated P 2
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Venous gangrene
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%uptured ba1er)s cyst#
+al muscle haematoma# %uptured plantaris muscle#
!hrombosed popliteal aneurysm
Arterial ischemia
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Diagnosis
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Clinical variable Score
Active cancer 3Paralysis # paresis# recent cast 3
'edridden or4 5 days # ma6or surgery
7 32 wee1s
3
!enderness along deep veindistribution
3
"ntire leg swelling 3
8nilateral cal swelling 45 cm 3
Pitting edema 3
+ollateral super*cial non varicose veins 3
Alternate dia nosis at least li1el as -2 9: # $ 3#2 H;5
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Venous 8S<3 ac1 o vein compressibility=principal>
Absence o ?win1@ on crosssection
,ailure to oppose walls dueto passive distension
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2 !hrombus
homogenous # lowechogenecity
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5 +al compression blunts
doppler fow signal
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Management
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ProphylaisLow B young# minor illness # operations
lasting 75:
Moderate B 4 C: or with a debilitating illnesswho are to undergo ma6or surgery.
igh B 3> 4C: who have seriousaccompanying medical conditions= +VA $I>#
2>ma6or surgery with an additional ris1actor =past history o venousthromboembolism or 1nown malignantdisease.>
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High-ris1 general surgery-$ini-8,H or $EH
!horacic surgery- $ini-8,H FIP+
+ancer surgery - $EH#consider 3 month oprophylais
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!otal hip replacement#
total 1nee replacement# hipracture - $EH#ondaparinu
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&eurosurgery - IP+
&eurosurgery or brain tumor-$ini-8,H or $EH# F IP+ Fpredischarge venous
ultrasonography $edically ill patients- $ini-8,H or $EH
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Anticoagulationcontraindicated - IP+
ong-haul air travel - $EHor very high-ris1 patients
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!reatment G
anticoagulationInitiation G 8,H # $EH #ondaparinu
Proven HI! G direct thrombininhibitor G agatroban #
lepirudin # bivalirudin$aintenance G wararin
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AP!! G 2 -5
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iv bolus - :::-3:::: 8
ollowed by inusion 3:::-3::8hr
Short t J
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<reater bio availability #
predictable # longer tJ"noaparin
alteparin
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,ondaparinu G anti Ka
pentasaccharide&o lab monitoring no HI!
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Eararin
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Initiated in mg dose
!arget I&% 2. =2-5>
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urationP" ater surgery# trauma#
or estrogen eposure-have a low rate orecurrence ater 5GLmonths oanticoagulation.
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V! isolated to an upperetremity or cal that has been
provo1ed by surgery# trauma#estrogen# or an indwelling centralvenous catheter or pacema1er- 5
months o anticoagulationsuMces.
,or provo1ed proimal leg V!
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cancer and V!"# 5GL monthso $EH as monotherapywithout wararin and tocontinue anticoagulation
inde*nitely unless the patientis rendered cancer-ree.
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Idiopathic# unprovo1ed
V!"# =incl long-haul airtravel> anticoagulationor an inde*nite durationwith a target I&% between2 and 5
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.moderate or high levels oanticardiolipin antibodies -inde*nite-durationanticoagulation even i the
initial V!" was provo1ed bytrauma
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,ibrinolysis
rtPA
Iliac vein thrombosis
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IV+ *lters
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Active bleeding
%ecurrent venousthrombosis despiteanticoagulation