2. 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. 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. 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 left 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
9. 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.
11. 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
12. 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
13. 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.
14.
15.
16.
17. 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)
18. 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
19. Inherited :
- Factor V Leiden mutation
- Antithrombin deficiency
- Protein C, S deficiency
- Prothrombin 20210 gene variant
- Homocysteinemia
22. Calf pain or tenderness or both
Swelling wit pitting edema
Increase in local temperature
Redness or discoloration
Dilatation of superficial veins
23.
24. Less frequent manifestations of DVT
includes
Phlegmasia cerulea dolens
Phlegmasia alba dolens
Venous gangrene
25. 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.
26.
27. 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
28.
29. Homan’s sign:
- Pain in the calf region or knee with forced
dorsiflexion
30. 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
31.
32.
33. 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
34. 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
39. 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.
40. 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.
41.
42. 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
43. 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
44. 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
45.
46. Muscular tear
Rupture of a Baker’s cyst
Cellulites or other infection
Thrombophlebitis
Tumors
Connective tissue disorders
47.
48. Tintinallis emergency medicine
Rosens emergency medicine
Dutton. Orthopedic examination, evaluation
and intervention
Belly and love surery
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