Post on 07-Jul-2018
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Yost
Surgery
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DVT/PEVirchow’s Triad: hypercoagulability, stasis, endothelial damage
DIFFERENTIAL DIAGNOSES
− DVT
− Compartment Syndrome
− Chronic Venous Insufficiency → ulceration
− Cellulitis → fever/chills, erythema, ↑WBCs − Decreased Venous Return → CHF, cirrhosis
− Trauma
− Lymphangitis
− Renal Failure
1) HISTORY
− HPI:
• Pain: PQRST
• Unilateral vs. Bilateral
• Swelling
• Recent ∆s: trauma, kidney problems
− ROS: F/C, SOB, pleuritic CP, cough, hemoptysis − PMHx: prior DVT, CA, coagulopathy (factor V leiden, homocysteinemia, anti-phospholipid Ab, polycythemia vera),
recent immobilization/paralysis, hospitalization in past 6 mos, pregnancy
− PSHx: trauma/surgery in prior 6 mos
− Meds/Allergies: HRT/OCP, warfarin, ASA
− FHx: DVT in ≥2 1° relatives, PE
− SHx: smoking, recent travel, occupation, EtOH, IVDU
2) PHYSICAL EXAM
− Vitals/General Appearance: ↑HR
− Cardiopulmonary: tachypnea, pleural friction rub (PE), tachycardia, S3 (CHF)
− EXT:
• Appearance: erythema, dilated superficial veins, color changes
• Palpation: warmth, localized tenderness along veins, palpable cord, calf >3cm larger than ASx side • Homan’s Sign: calf pain w/ dorsiflexion
3) LABS
− DVT: D-Dimers, CBC (↑ w/ polycythemia vera), coags
− PE: Coags, ABG (↓ pO2/pCO2 d/t hyperventiliation)
4) IMAGING/STUDIES
− DVT: duplex U/S
− PE: EKG, CXR, PT-protocol CT, pulse ox
5) TREATMENT
− Anticoagulation:
• Options:○ IV unfractionated heprin (100 U/kg bolus → 25 U/kg/hr for 4-6 days) → target PTT = 2x normal
+ Followed by warfarin → therapeutic INR = 2-3 ○ Lovenox + warfarin (starting on day 1 of Lovenox)
• Length:○ 1
st event: 3-6 months (known cause) vs 5 years (unknown etiology)
+ Once stopped→ d-dimer and U/S○ 2
nd event/active cause: 12 mos – lifelong
• Complications:
○ Heparin → HIT
○ Warfarin → hypercoagulable state in first several days
− TPA: only used in extensive cases of DVT/PE → causing hemodynamic compromise
− Thrombectomy: indicated in cases of limb-threatening ischemia
− Greenfield Filter: placed in IVC by IR • Indications: anticoag CI (GI bleed, recent CVA, cerebral AVM, hemophilia, pulm HTN, recurrent DVT/PE)
− Complications
• Recurrence → most common in 1st few months
○ Tx: admit to hospital, IV heparin, support hose
• Post-Thrombotic Syndrome (10%) → edema, ulceration @ ankles, venous claudication, pain, color ∆s○ Tx: support hose
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• Unstable: arteriography (detects rates ≥ 0.5 cc/min) → potentially tx-ic (vasopressin injxn/embolization)
• Surgical Tx: >6U pRBCs/24h; >3U pRBCs to stabilize; big rebleed (esp if known site), CA/obstrxn/perf ○ Known site w/ massive bleeding: segmental resection ○ Unknown site: ex-lap (+/- SI enteroscopy) + subtotal colectomy w/ ileorectal anastomosis
• /↓
endoscopy fail: capsule endo, push enteroscopy, enteroclysis, bleeding scan, Tc-99/merkel scan
− Tx:
• Diverticulitis: bleeding usually stops spontaneously
○ Endoscopic Tx (epi injxns), arterial vasopressin, embolization, surgery → other options ○ Surgical Indications: Cx (fistula/obstrxn/stricture), recurrent episodes, hemorrhage, CA, abscess
• Fissure: sitz baths, stool softeners, ↑ fiber diet, topical CaCB, surgery = lateral internal sphincterotomy
• Hemorrhoids: same as fissure + band ligation, surgery → hemorrhoidectomy ○ Hemorrhoidectomy Cx: exsanguinations (in colon lumen), infection, incontinence, anal stricture
• Bleeding Polyps/Vascular Ectasias: laser, electrocoagulation, local epi injection
• Angiodysplasia: arterial vasopressin, endoscopic tx (epi), surgery, hormonal risk• Unknown Etiology w/ Unstable Patient: total abdominal colectomy (85% effective)
○ Reconstruct w/ ileostomy or ileorectal anastamosis
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