Venous thromboembolism (VTE) includes pulmonary embolism (PE) and deep vein thrombosis (DVT). VTE results from Virchow's triad of stasis, endothelial injury, and hypercoagulability. Clinical diagnosis of PE is difficult due to vague symptoms in most patients. Wells criteria and D-dimer testing are used to determine pre-test probability before confirmatory tests like CT angiography (CTA) or ventilation-perfusion (V/Q) scanning. Treatment involves anticoagulation with heparin or low molecular weight heparin initially, followed by vitamin K antagonist therapy. Fibrinolytics or embolectomy may be used for high-
This document discusses venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). It covers Virchow's triad as the underlying causes of VTE, clinical presentation of PE, diagnostic tests including D-dimer and imaging, risk stratification for PE-related mortality, anticoagulation treatment including heparin and warfarin, and hemodynamic and respiratory support for high-risk PE patients. Key points include that >90% of PEs originate from the leg deep veins, recurrence is higher for iliac vein thrombosis, and diagnostic algorithms involve assessing clinical probability and using tests like CT, ultrasound, and D-dimer.
This document summarizes pulmonary embolism (PE), including epidemiology, symptoms, diagnostic criteria like the Wells criteria and PERC rule, diagnostic tests like CT pulmonary angiography and V/Q scan, treatment with anticoagulation and thrombolytics, and classifications of massive versus submassive PE.
The document discusses acute pulmonary embolism (PE). PE is common but difficult to diagnose, with nonspecific symptoms. It describes a case of a 48-year-old woman presenting with sudden dyspnea, tachycardia, and leg swelling who may have PE. Risk factors for PE include recent surgery or trauma, prolonged immobilization, and inherited or acquired hypercoagulable states. Diagnosis involves clinical scoring, D-dimer, imaging like CTPA, and treatment includes anticoagulation with heparin or warfarin.
This document discusses acute pulmonary embolism, including its causes, symptoms, diagnosis, and treatment. It notes that PE is a leading cause of preventable hospital death and that diagnosis can be difficult due to non-specific symptoms. The diagnosis involves a clinical probability assessment, d-dimer test, and CT scan. Treatment depends on risk stratification and may involve anticoagulation, thrombolysis for massive PE, or placement of an IVC filter. Prevention through prophylaxis in at-risk patients is emphasized.
Pulmonary embolism (PE) is a common and potentially fatal cardiovascular condition caused by blood clots in the lungs. The document discusses the classification, pathophysiology, risk factors, clinical features, diagnostic testing and management of PE. Key points include that PE has a 15% fatality rate if untreated, but mortality decreases to around 10% with anticoagulation therapy. Rapid risk stratification and treatment of high-risk PE cases with thrombolysis, surgery or other interventions is important for reducing mortality.
This document provides an overview of deep vein thrombosis (DVT) and pulmonary embolism (PE). It covers the definition, epidemiology, risk factors, clinical features, investigations, management including prevention, treatment and anticoagulation. DVT occurs when a blood clot forms in a deep vein, usually in the legs, while PE is a complication that can occur when part of the clot breaks off and travels to the lungs. The document outlines Virchow's triad of factors that contribute to clot formation and discusses various diagnostic tests and therapeutic approaches for DVT and PE.
1) Pulmonary thromboembolism (PTE) is caused by obstruction of pulmonary vessels, usually by blood clots. Risk factors include hypercoagulability, recent surgery or trauma, pregnancy, genetic mutations.
2) Diagnostic tests include D-dimer, chest CT, lung scan, echocardiogram. Chest CT has replaced lung scan as the primary imaging test.
3) Treatment involves resuscitation for massive PTE, anticoagulation with heparin or low molecular weight heparin initially followed by warfarin for at least 3 months, and potentially thrombolysis for selected high-risk cases or inferior vena cava filters for recurrent clots despite
This document discusses pulmonary embolism (PE). It notes that PE is a common disorder that can be deadly if left untreated. The presentation of PE is often vague and nonspecific. While the classic triad of symptoms is hemoptysis, dyspnea, and pleuritic pain, this occurs in less than 20% of patients. The document reviews risk factors, clinical features, diagnostic testing options including Wells criteria, imaging studies, D-dimer testing and their limitations. Treatment involves anticoagulation with heparin or warfarin to prevent clot extension and recurrence while educating patients.
This document discusses venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). It covers Virchow's triad as the underlying causes of VTE, clinical presentation of PE, diagnostic tests including D-dimer and imaging, risk stratification for PE-related mortality, anticoagulation treatment including heparin and warfarin, and hemodynamic and respiratory support for high-risk PE patients. Key points include that >90% of PEs originate from the leg deep veins, recurrence is higher for iliac vein thrombosis, and diagnostic algorithms involve assessing clinical probability and using tests like CT, ultrasound, and D-dimer.
This document summarizes pulmonary embolism (PE), including epidemiology, symptoms, diagnostic criteria like the Wells criteria and PERC rule, diagnostic tests like CT pulmonary angiography and V/Q scan, treatment with anticoagulation and thrombolytics, and classifications of massive versus submassive PE.
The document discusses acute pulmonary embolism (PE). PE is common but difficult to diagnose, with nonspecific symptoms. It describes a case of a 48-year-old woman presenting with sudden dyspnea, tachycardia, and leg swelling who may have PE. Risk factors for PE include recent surgery or trauma, prolonged immobilization, and inherited or acquired hypercoagulable states. Diagnosis involves clinical scoring, D-dimer, imaging like CTPA, and treatment includes anticoagulation with heparin or warfarin.
This document discusses acute pulmonary embolism, including its causes, symptoms, diagnosis, and treatment. It notes that PE is a leading cause of preventable hospital death and that diagnosis can be difficult due to non-specific symptoms. The diagnosis involves a clinical probability assessment, d-dimer test, and CT scan. Treatment depends on risk stratification and may involve anticoagulation, thrombolysis for massive PE, or placement of an IVC filter. Prevention through prophylaxis in at-risk patients is emphasized.
Pulmonary embolism (PE) is a common and potentially fatal cardiovascular condition caused by blood clots in the lungs. The document discusses the classification, pathophysiology, risk factors, clinical features, diagnostic testing and management of PE. Key points include that PE has a 15% fatality rate if untreated, but mortality decreases to around 10% with anticoagulation therapy. Rapid risk stratification and treatment of high-risk PE cases with thrombolysis, surgery or other interventions is important for reducing mortality.
This document provides an overview of deep vein thrombosis (DVT) and pulmonary embolism (PE). It covers the definition, epidemiology, risk factors, clinical features, investigations, management including prevention, treatment and anticoagulation. DVT occurs when a blood clot forms in a deep vein, usually in the legs, while PE is a complication that can occur when part of the clot breaks off and travels to the lungs. The document outlines Virchow's triad of factors that contribute to clot formation and discusses various diagnostic tests and therapeutic approaches for DVT and PE.
1) Pulmonary thromboembolism (PTE) is caused by obstruction of pulmonary vessels, usually by blood clots. Risk factors include hypercoagulability, recent surgery or trauma, pregnancy, genetic mutations.
2) Diagnostic tests include D-dimer, chest CT, lung scan, echocardiogram. Chest CT has replaced lung scan as the primary imaging test.
3) Treatment involves resuscitation for massive PTE, anticoagulation with heparin or low molecular weight heparin initially followed by warfarin for at least 3 months, and potentially thrombolysis for selected high-risk cases or inferior vena cava filters for recurrent clots despite
This document discusses pulmonary embolism (PE). It notes that PE is a common disorder that can be deadly if left untreated. The presentation of PE is often vague and nonspecific. While the classic triad of symptoms is hemoptysis, dyspnea, and pleuritic pain, this occurs in less than 20% of patients. The document reviews risk factors, clinical features, diagnostic testing options including Wells criteria, imaging studies, D-dimer testing and their limitations. Treatment involves anticoagulation with heparin or warfarin to prevent clot extension and recurrence while educating patients.
This document provides information on venous thromboembolic diseases including definitions, key priorities for implementation, diagnosis, treatment, thrombophilia testing, and investigations for cancer. Regarding diagnosis, it outlines diagnostic investigations and scoring systems for deep vein thrombosis (DVT) and pulmonary embolism (PE). Treatment includes pharmacological interventions like anticoagulants and thrombolytic therapy, as well as mechanical interventions. It also discusses providing patient information and thrombophilia testing guidelines.
Deep vein thrombosis (DVT) is a common and potentially fatal condition. It can lead to pulmonary embolism (PE), which is a leading cause of preventable hospital death. While DVT often has no symptoms, it puts patients at risk for long-term complications. Standard diagnostic tests include ultrasound, CT scans, and D-dimer tests. Risk factors include surgery, trauma, immobility, and cancer. Prophylaxis with blood thinners, compression devices, and stockings can significantly reduce the risk of DVT, especially in high-risk hospitalized patients. Early diagnosis and treatment are important to prevent fatal PE and long-term issues.
Physician should have a high suspicion to diagnose patient with pulmonary Embolism, this slides will give you precise Diagnosis, Investigation and guideline directed Treatment.
This document provides information on acute pulmonary embolism (PE), including its definition, risk factors, pathophysiology, clinical features, diagnostic tests, treatment with anticoagulation therapy, and classifications. It describes PE as obstruction of the pulmonary artery or its branches by material originating elsewhere. Risk factors include older age, surgery, trauma, cancers, and prolonged immobilization. Diagnostic tests include D-dimer, CT pulmonary angiogram, ventilation-perfusion scan, echocardiogram, and angiogram. Treatment involves anticoagulation therapy such as low molecular weight heparin, fondaparinux, warfarin, or direct oral anticoagulants. Duration of therapy depends on whether the PE was
This document discusses the diagnostic and treatment approaches to venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). It provides details on evaluating patients using Wells criteria and D-dimer testing to determine pre-test probability and decide between imaging with CT pulmonary angiogram or VQ scan. For confirmed VTE, treatment options include warfarin, novel oral anticoagulants (NOACs), inferior vena cava filters or thrombolytics. The document reviews best practices for treating isolated distal DVT, catheter-related thrombosis, and selecting appropriate long-term anticoagulation therapy.
This document discusses pulmonary embolism (PE), including its causes, symptoms, diagnosis, and treatment. Some key points:
- PE is a common cause of preventable death, often occurring without warning signs. Prompt diagnosis and treatment are important.
- PE usually originates from blood clots that form in the deep leg veins. Symptoms can include chest pain, difficulty breathing, and syncope.
- Diagnosis is difficult as symptoms are non-specific. Imaging tests like CT scans are often needed along with blood tests like d-dimers.
- Treatment involves blood thinners to prevent further clots. Thrombolysis may be used in high-risk cases but risks need to be weighed
Deep Vein Thrombosis and Pulmonary Embolism, by Prof. Minnu M. PanditraoMinnu Panditrao
Dr. Mrs. Minnu Panditrao, goes in depth with the very important topic of Deep Vein Thrombosis, Pulmonary embolism, aetio patheogenesis, clinical features, management etc.
1. A 35-year-old man presented with acute onset of breathlessness and was found to have pulmonary thromboembolism and deficiencies in protein C and protein S without evidence of deep vein thrombosis.
2. He was treated with supportive measures, heparin, acenocoumarol, and supplements but developed massive hemoptysis and succumbed to his illness despite intensive care.
3. The case report discusses evaluation, treatment, and long-term management of venous thromboembolism and highlights complications that can arise.
VTE refers to deep vein thrombosis and pulmonary embolism, which share common risk factors and pathophysiology. Risk factors include immobilization, recent surgery or trauma, inherited or acquired hypercoagulable states, and certain medical conditions. Signs and symptoms of DVT include leg pain and swelling, while PE presents with dyspnea, chest pain, and potentially hemodynamic instability in severe cases. Diagnosis involves clinical assessment, imaging like ultrasound or CT, and blood tests like D-dimer and Wells criteria. Treatment consists of anticoagulation with heparins or warfarin to prevent clot extension and recurrence.
This document discusses the pathophysiology and treatment of acute pulmonary embolism (PE). It covers:
- The pathophysiological effects of PE on right ventricular function and hemodynamics.
- Clinical prediction rules and diagnostic strategies for PE including D-dimer testing and imaging modalities like CT, VQ scan, and angiography.
- Treatment options for PE including anticoagulants like heparin, low molecular weight heparin, fondaparinux, and newer oral agents; as well as thrombolytics, vena cava filters, and embolectomy. LMWH is recommended as first-line treatment due to superior safety compared to unfractionated heparin
The document discusses venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE). It notes that VTE is a common cause of preventable hospital death. Risk factors include immobilization, previous DVT history, malignancy, and inherited thrombophilias. Diagnosis involves tests like ultrasound and D-dimer. Treatment includes anticoagulation with drugs like heparin and warfarin. Complications can include PE, chronic venous insufficiency, and venous gangrene. Unusual sites of DVT discussed include upper extremities, mesenteric veins, and renal veins.
Pulmonary thromboembolism is caused by obstruction of pulmonary vessels, usually by blood clots. Clots can form in the lungs (primary) or originate elsewhere and travel to the lungs (secondary). Symptoms range from none (silent) to chest pain, dyspnea, tachycardia, and hemodynamic instability. Diagnosis involves evaluating likelihood based on risk factors and symptoms, d-dimer testing, imaging like CT, lung scan, or echocardiogram. Treatment is anticoagulation with heparin or warfarin long term. For some high risk cases thrombolysis or embolectomy may be considered.
This document discusses the challenges of managing anticoagulation in patients undergoing surgical procedures. It provides guidance on estimating thromboembolic and bleeding risk, deciding whether to interrupt anticoagulation, and timing interruptions. For patients at very high thromboembolic risk, the goal is to limit time off anticoagulation. Bleeding risk depends on procedure type and duration. Warfarin should be stopped 5 days before elective surgery to allow the INR to decrease safely.
RTD - Xarelto for Venous Thromboembolism (VTE) Patients.pptxHandiRosiyanto
1) The document discusses evidence on the use of direct oral anticoagulants (DOACs) for the treatment of venous thromboembolism (VTE) including deep vein thrombosis (DVT) and pulmonary embolism (PE).
2) Both the ACCP and ASH guidelines support the use of DOACs over vitamin K antagonists for the treatment of DVT and PE due to comparable or better efficacy and safety profiles.
3) The document reviews risk assessment models for VTE and bleeding risks, diagnostic criteria and methods for DVT and PE, and treatment recommendations including duration of anticoagulation based on risk factors.
Pulmonary embolism (PE) is a potentially life-threatening condition with an estimated incidence between 0.5-3% in the general population. Risk factors include previous DVT, immobilization, surgery, cancer, and certain genetic conditions. Symptoms are nonspecific but commonly include dyspnea, chest pain, and cough. Diagnostic tests include D-dimer, CT pulmonary angiogram (CTPA), ventilation-perfusion scan, and pulmonary angiogram. Clinical decision rules like Wells criteria are used to determine pre-test probability to guide appropriate testing. The diagnostic algorithm involves using Wells criteria and D-dimer to determine if CTPA is needed, with CTPA used to confirm or exclude the diagnosis in
DVT is the formation of a blood clot in the deep veins, usually in the legs. Risk factors include age, immobilization, pregnancy, cancer, family history. Symptoms are leg swelling, pain, shortness of breath. Diagnosis involves a physical exam, Wells score, D-dimer test, ultrasound or CT scan. Treatment is blood thinners like heparin or warfarin to prevent clots from getting worse or causing pulmonary embolisms.
A pulmonary embolism occurs when a blood clot or other material occludes the pulmonary artery or its branches. This most commonly results from a deep vein thrombosis in the lower leg that embolizes to the lung. When a PE occurs, it causes ventilation-perfusion mismatching in the lungs. Diagnosis is difficult due to nonspecific symptoms but evaluation involves a Wells criteria assessment, D-dimer testing, echocardiogram, and CT pulmonary angiogram. Treatment consists of anticoagulation with low molecular weight heparin or novel oral anticoagulants. Fibrinolytic therapy may be used in massive PEs. Prevention focuses on prophylaxis in high risk hospitalized patients.
1) Pulmonary embolism is a blockage in the pulmonary artery or its branches by a blood clot that originated in the veins, causing serious health risks.
2) Risk factors include prolonged bed rest, cancer, smoking, oral contraceptive use, and pregnancy. Symptoms include dyspnea, chest pain, cough, and leg pain. Diagnosis involves tests like CT pulmonary angiography and ventilation-perfusion scanning.
3) Treatment involves oxygen, anticoagulant drugs like heparin and warfarin, and sometimes surgical embolectomy for severe cases. Prevention focuses on leg exercises, early ambulation, and compression stockings.
1) Pulmonary embolism is a blockage in the pulmonary artery or its branches by a blood clot that originated in the veins, causing serious health risks.
2) Risk factors include prolonged bed rest, cancer, smoking, oral contraceptive use, and pregnancy. Symptoms include dyspnea, chest pain, cough, and leg pain. Diagnosis involves tests like CT pulmonary angiography and ventilation-perfusion scanning.
3) Treatment involves oxygen, anticoagulant drugs like heparin and warfarin, and sometimes surgical embolectomy for severe cases. Prevention focuses on leg exercises, early ambulation, and compression stockings.
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
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Semelhante a Venous Thrombosis Emboli disease and how to manage it
This document provides information on venous thromboembolic diseases including definitions, key priorities for implementation, diagnosis, treatment, thrombophilia testing, and investigations for cancer. Regarding diagnosis, it outlines diagnostic investigations and scoring systems for deep vein thrombosis (DVT) and pulmonary embolism (PE). Treatment includes pharmacological interventions like anticoagulants and thrombolytic therapy, as well as mechanical interventions. It also discusses providing patient information and thrombophilia testing guidelines.
Deep vein thrombosis (DVT) is a common and potentially fatal condition. It can lead to pulmonary embolism (PE), which is a leading cause of preventable hospital death. While DVT often has no symptoms, it puts patients at risk for long-term complications. Standard diagnostic tests include ultrasound, CT scans, and D-dimer tests. Risk factors include surgery, trauma, immobility, and cancer. Prophylaxis with blood thinners, compression devices, and stockings can significantly reduce the risk of DVT, especially in high-risk hospitalized patients. Early diagnosis and treatment are important to prevent fatal PE and long-term issues.
Physician should have a high suspicion to diagnose patient with pulmonary Embolism, this slides will give you precise Diagnosis, Investigation and guideline directed Treatment.
This document provides information on acute pulmonary embolism (PE), including its definition, risk factors, pathophysiology, clinical features, diagnostic tests, treatment with anticoagulation therapy, and classifications. It describes PE as obstruction of the pulmonary artery or its branches by material originating elsewhere. Risk factors include older age, surgery, trauma, cancers, and prolonged immobilization. Diagnostic tests include D-dimer, CT pulmonary angiogram, ventilation-perfusion scan, echocardiogram, and angiogram. Treatment involves anticoagulation therapy such as low molecular weight heparin, fondaparinux, warfarin, or direct oral anticoagulants. Duration of therapy depends on whether the PE was
This document discusses the diagnostic and treatment approaches to venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). It provides details on evaluating patients using Wells criteria and D-dimer testing to determine pre-test probability and decide between imaging with CT pulmonary angiogram or VQ scan. For confirmed VTE, treatment options include warfarin, novel oral anticoagulants (NOACs), inferior vena cava filters or thrombolytics. The document reviews best practices for treating isolated distal DVT, catheter-related thrombosis, and selecting appropriate long-term anticoagulation therapy.
This document discusses pulmonary embolism (PE), including its causes, symptoms, diagnosis, and treatment. Some key points:
- PE is a common cause of preventable death, often occurring without warning signs. Prompt diagnosis and treatment are important.
- PE usually originates from blood clots that form in the deep leg veins. Symptoms can include chest pain, difficulty breathing, and syncope.
- Diagnosis is difficult as symptoms are non-specific. Imaging tests like CT scans are often needed along with blood tests like d-dimers.
- Treatment involves blood thinners to prevent further clots. Thrombolysis may be used in high-risk cases but risks need to be weighed
Deep Vein Thrombosis and Pulmonary Embolism, by Prof. Minnu M. PanditraoMinnu Panditrao
Dr. Mrs. Minnu Panditrao, goes in depth with the very important topic of Deep Vein Thrombosis, Pulmonary embolism, aetio patheogenesis, clinical features, management etc.
1. A 35-year-old man presented with acute onset of breathlessness and was found to have pulmonary thromboembolism and deficiencies in protein C and protein S without evidence of deep vein thrombosis.
2. He was treated with supportive measures, heparin, acenocoumarol, and supplements but developed massive hemoptysis and succumbed to his illness despite intensive care.
3. The case report discusses evaluation, treatment, and long-term management of venous thromboembolism and highlights complications that can arise.
VTE refers to deep vein thrombosis and pulmonary embolism, which share common risk factors and pathophysiology. Risk factors include immobilization, recent surgery or trauma, inherited or acquired hypercoagulable states, and certain medical conditions. Signs and symptoms of DVT include leg pain and swelling, while PE presents with dyspnea, chest pain, and potentially hemodynamic instability in severe cases. Diagnosis involves clinical assessment, imaging like ultrasound or CT, and blood tests like D-dimer and Wells criteria. Treatment consists of anticoagulation with heparins or warfarin to prevent clot extension and recurrence.
This document discusses the pathophysiology and treatment of acute pulmonary embolism (PE). It covers:
- The pathophysiological effects of PE on right ventricular function and hemodynamics.
- Clinical prediction rules and diagnostic strategies for PE including D-dimer testing and imaging modalities like CT, VQ scan, and angiography.
- Treatment options for PE including anticoagulants like heparin, low molecular weight heparin, fondaparinux, and newer oral agents; as well as thrombolytics, vena cava filters, and embolectomy. LMWH is recommended as first-line treatment due to superior safety compared to unfractionated heparin
The document discusses venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE). It notes that VTE is a common cause of preventable hospital death. Risk factors include immobilization, previous DVT history, malignancy, and inherited thrombophilias. Diagnosis involves tests like ultrasound and D-dimer. Treatment includes anticoagulation with drugs like heparin and warfarin. Complications can include PE, chronic venous insufficiency, and venous gangrene. Unusual sites of DVT discussed include upper extremities, mesenteric veins, and renal veins.
Pulmonary thromboembolism is caused by obstruction of pulmonary vessels, usually by blood clots. Clots can form in the lungs (primary) or originate elsewhere and travel to the lungs (secondary). Symptoms range from none (silent) to chest pain, dyspnea, tachycardia, and hemodynamic instability. Diagnosis involves evaluating likelihood based on risk factors and symptoms, d-dimer testing, imaging like CT, lung scan, or echocardiogram. Treatment is anticoagulation with heparin or warfarin long term. For some high risk cases thrombolysis or embolectomy may be considered.
This document discusses the challenges of managing anticoagulation in patients undergoing surgical procedures. It provides guidance on estimating thromboembolic and bleeding risk, deciding whether to interrupt anticoagulation, and timing interruptions. For patients at very high thromboembolic risk, the goal is to limit time off anticoagulation. Bleeding risk depends on procedure type and duration. Warfarin should be stopped 5 days before elective surgery to allow the INR to decrease safely.
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1) The document discusses evidence on the use of direct oral anticoagulants (DOACs) for the treatment of venous thromboembolism (VTE) including deep vein thrombosis (DVT) and pulmonary embolism (PE).
2) Both the ACCP and ASH guidelines support the use of DOACs over vitamin K antagonists for the treatment of DVT and PE due to comparable or better efficacy and safety profiles.
3) The document reviews risk assessment models for VTE and bleeding risks, diagnostic criteria and methods for DVT and PE, and treatment recommendations including duration of anticoagulation based on risk factors.
Pulmonary embolism (PE) is a potentially life-threatening condition with an estimated incidence between 0.5-3% in the general population. Risk factors include previous DVT, immobilization, surgery, cancer, and certain genetic conditions. Symptoms are nonspecific but commonly include dyspnea, chest pain, and cough. Diagnostic tests include D-dimer, CT pulmonary angiogram (CTPA), ventilation-perfusion scan, and pulmonary angiogram. Clinical decision rules like Wells criteria are used to determine pre-test probability to guide appropriate testing. The diagnostic algorithm involves using Wells criteria and D-dimer to determine if CTPA is needed, with CTPA used to confirm or exclude the diagnosis in
DVT is the formation of a blood clot in the deep veins, usually in the legs. Risk factors include age, immobilization, pregnancy, cancer, family history. Symptoms are leg swelling, pain, shortness of breath. Diagnosis involves a physical exam, Wells score, D-dimer test, ultrasound or CT scan. Treatment is blood thinners like heparin or warfarin to prevent clots from getting worse or causing pulmonary embolisms.
A pulmonary embolism occurs when a blood clot or other material occludes the pulmonary artery or its branches. This most commonly results from a deep vein thrombosis in the lower leg that embolizes to the lung. When a PE occurs, it causes ventilation-perfusion mismatching in the lungs. Diagnosis is difficult due to nonspecific symptoms but evaluation involves a Wells criteria assessment, D-dimer testing, echocardiogram, and CT pulmonary angiogram. Treatment consists of anticoagulation with low molecular weight heparin or novel oral anticoagulants. Fibrinolytic therapy may be used in massive PEs. Prevention focuses on prophylaxis in high risk hospitalized patients.
1) Pulmonary embolism is a blockage in the pulmonary artery or its branches by a blood clot that originated in the veins, causing serious health risks.
2) Risk factors include prolonged bed rest, cancer, smoking, oral contraceptive use, and pregnancy. Symptoms include dyspnea, chest pain, cough, and leg pain. Diagnosis involves tests like CT pulmonary angiography and ventilation-perfusion scanning.
3) Treatment involves oxygen, anticoagulant drugs like heparin and warfarin, and sometimes surgical embolectomy for severe cases. Prevention focuses on leg exercises, early ambulation, and compression stockings.
1) Pulmonary embolism is a blockage in the pulmonary artery or its branches by a blood clot that originated in the veins, causing serious health risks.
2) Risk factors include prolonged bed rest, cancer, smoking, oral contraceptive use, and pregnancy. Symptoms include dyspnea, chest pain, cough, and leg pain. Diagnosis involves tests like CT pulmonary angiography and ventilation-perfusion scanning.
3) Treatment involves oxygen, anticoagulant drugs like heparin and warfarin, and sometimes surgical embolectomy for severe cases. Prevention focuses on leg exercises, early ambulation, and compression stockings.
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5. Clinical Presentation of acute PE
• Clinical Signs and Symptoms are frequently vague
, Less specific and rarely “classic”
• Untreated mortality rate of 20% - 30%, reduce to
5% with timely intervention
Eur Heart J 2000; 21: 130-6
6. ESC Guidelines, 2008
Clinical Presentation Suspected Acute PE
• The Classic Triad to Suspected acute PE :
• Dyspnea
• Pleuritic pain or chest pain
• Hemoptysis
Occurs in less than 20% of patients with documented acute PE
7. How to increase clinical validity
if clinical acute PE less specific ?
Should be used Well’s Score
• Low probability category : 10% of acute PE
• Intermediate probability category: 30% of acute PE
• High probability category : 65% of acute PE
Just be applicated in Normotensive PE
Ann Intem
Med, 2006;
12. Diagnosis Suspected of PE
Clinical Presentations
ECG
X photo Thorax
+
Hemodynamic State :
• Normotensive Suspected non-high risk acute PE
• Hypotensive Suspected high risk acute PE
13. Clinical Suspected high-risk PE
i.e with shock or hypotension
CT immediately available
Echocardiography
PE-specific
Fibrinolytic
or embolectomy
Search for the other causes
Fibrinolytic /embolectomy
not justified
Normal
Abnormal
No other tests available
or patient unstable
CT available and
patient stabilized
RV overload
Search for the other causes
No Yes
No Yes CTA
ESC Guidelines, 2008
14. Clinical Suspected non-high-risk PE
i.e Normotensive
Well’s Score
No PE
No treatment or
Investigate further
PE
Anticoagulant
Treatment
500 mg/L
PE
Anticoagulant
Treatment
< 500 mg/L
No Treatment
D-dimer
Low / intermediate
probability
High probability
No PE
No Treatment
CTA
ESC Guidelines, 2008
CTA
16. Pretest Probability of Wells Score
ESC Guidelines, 2008
Variables Points
Previous acute DVT or PE
Recent surgery or immobilization
Cancer
+1.5
+1.5
+1
Haemoptysis +1
Heart Rate >100 beats/min
Clinical signs of DVT
+1.5
+3
Alternative diagnosis less likely than
PE
- 3
Low
Intermediate
High
0 -1
2 -6
7
PE unlikely
PE likely
0 - 4
> 4
20. D-dimer Test
Fibrin split product
Circulating half-life of 4-6 hours
Positive Value : ≥ 500 mg/dl(PE), ≥ 900 mg/dl(DVT) has many
False Positives .
Negative Value : < 500 mg/dl(PE),<900mg/dl(DVT) has a high and
93-100% negative predictive value ( 93 – 100 % ) to rule out acute
PE
False Positives:
VTE
Pregnant Patients Post-partum < 1 week
Malignancy Surgery within 1 week
Advanced age > 80 years Sepsis
Hemmorrhage CVA
AMI Collagen Vascular Diseases
Hepatic Impairment
30. The aim of Blood Test
1. Blood Gas Analysis – Follow Up Clinical Progress in Hospitalized
2. Thrombophilia testing - How long anticoagulant to be given ?
Indication to screening test : History of unexplained or rcurrent
thrombosis and /or pregnancy complication.
Test Include :
ACAIgG ,ACAIgM, Protein S & C, AT III, APC, Fibrinogen, Homo-
cystein,CRP, Factor VIII.
Thrombophilia proven Long life anticoagulant maintenance
Thrombophilia unproven 3- 12 bulanantcoagulant maintenance
32. Anticoagulants for Acute PE
TYPES THERAPEUTIC DOSE RECOMMENDATION Grade of
Evidence
Unfractionated
Heparin
- Bolus 5000 Unit per IV
- maintain 1000 U/hr per drip
- aPTT target 2-3 times of unl
- given for 5 days
Non-high risk PE 1 A
Enoxaparin -1 mg/kg every 12 hours
- given for 5 days
Non-high risk PE
LMWH over UFH
1 A
Fondaparinux - 5 mg / 24 hr for <50 kg weight
- 7.5 mg/24 hr for 50-100 kg wght
- 10 mg / 24 hr for >100 kg weight
- given for 5 days
Non-high risk PE Indefinite
Warfarin /
Coumadin
- 2-10 mg/day
- INR target 2.5-3
- given overlapping in 3rd day
during UHF/Enoxa/Fonda
Usual
maintenance
1 A
Am J Med, 2007; 120: 18-25
33. Fibrinolytic for Acute PE
TYPES THERAPEUTIC DOSE RECOMMENDATION Grade of
Evidence
Streptokinase - Bolus 250.000 U/IV for 30
minutes
- Maintain 100.000 U/hr for
24 hours
High risk PE 1 C
Urokinase - Bolus 4400 U/kg for 10 mnt
- Maintain 2000 U/kg/hr for
12 hours
High risk PE 1 C
tPA 100 mg IV over 2 hours High risk PE 1 C
Note: No evidence catheter-directed method (local) has greater benefit than
systemic intravenous
Am J Med, 2007; 120: 18-25
34. Embolectomy for Acute PE
TYPES RECOMMENDATION Grade of
Evidence
Mechanical
percutaneous
embolectomy (MPE)
High risk PE who are unable to receive
fibrinolytic therapy
2 C
Note:
- Grade 1: Strong recommendation
- Grade 2: Weaker recommendation
- Level of evidence A: RCTs with consistent result
- Level of evidence B: RCTs with inconsistent result
- Level of evidence C: Observational studies
Am J Med, 2007; 120: 18-25
36. Mrs. AN, 37 y.o
• Dyspnea, 1 bed pillow, couging up blood
since 3 days ago.
• Left leg swelling then massaged about 6
days earlier and diagnosed DVT by doctor
• Denied Asthma, TBC and heart disease
• C M, JVP stable,TD 120/80 mmHg.HR 105 x
/mnt
Lung : Wheezing & Rales (-)
Left Leg: Edema & Warm .
Os ke RS
- ECG : Sinus Tachycardi
- Thorax Photo : WNL
,
WD/ Suspect Low Risk PE
What Next ?
Well’s Score
37. Pretest Probability of Wells Score
Variables Points
Previous acute DVT or PE
Recent surgery or immobilization
Cancer
+1.5
+1.5
+1
Haemoptysis +1
Heart Rate >100 beats/min
Clinical signs of DVT
+1.5
+3
Alternative diagnosis less likely than
PE
- 3
Low
Intermediate
High
0 -1
2 -6
7
PE unlikely
PE likely
0 - 4
> 4
Points
+1.5
-
-
+1
+1.5
+3
-
7 High
PE Likely
38. Suspect Low Risk PE
Well Score , High Probability
What Next ?
CTA
41. Background
DVT is common but elusive illness
In 1644, Schenk
In 1846,Virchow
The worldwide incidence 100 cases per 100,000 person,
annually
The incidence in Asians is 2.2 - 62.5 %
42. Complication of DVT
1. Pulmonary Embolism is the cause of death in 0.9 %
2. Post Thrombotic Syndrome 60 - 85 %
( Venous Hypertension Venous Reflux - CVI )
3. Phlegmasia Cerulea Dolens 1 – 6 %
43. The Surgical risk of Deep Vein Thrombosis
• 16 - 30 % in general surgical
• 45 - 70 % in orthopedic surgery
• 7 - 45 % in gynecologic surgery
• 25 % in urologic surgery
52. Wells Score
Clincal Features Score
- Active cancer 1
- Paralysis, recent plaster cast 1
- Recent immobilisation or surgery 1
- Tenderness along entire deep vein system 1
- Swelling of entire leg 1
- > 3 cm difference in calf circumference compared
with other leg 1
- Pitting oedema 1
- Collateral superficial veins (non Varicose) 1
- Alternative diagnosis as likely as DVT -2
High probability > 3
Moderate probability 1-2
Low Probability < 1 Interobserver reliability kappa 0.85
The prevalence of disease in each pre-test category was 85,33 and 5 % for the
high, moderate,and low probability groups, respectively.
Wells PS et al.
Lancet 1997 ; 350 : 1795-8
56. Anticoagulants for Acute DVT
TYPES THERAPEUTIC DOSE RECOMMENDATION Grade of
Evidence
Unfractionated
Heparin
- Bolus 5000 Unit per IV
- maintain 1000 U/hr per drip
- aPTT target 2-3 times of unl
- given for 5 days
- Proximal
- Distal with
severe risK
1 A
Enoxaparin -1 mg/kg every 12 hours
- given for 5 days
- Proximal
- Distal with
severe risK
1 A
Fondaparinux - 5 mg / 24 hr for <50 kg weight
- 7.5 mg/24 hr for 50-100 kg wght
- 10 mg / 24 hr for >100 kg weight
- given for 5 days
-Proximal
- Distal with
severe risK
1 A
Warfarin / - 2-10 mg/day Usual 1 A
57. Fibrinolytic for Acute DVT
TYPES THERAPEUTIC DOSE RECOMMENDATION Grade of
Evidence
Streptokinase - Bolus 250.000 U/IV for 30
minutes
- Maintain 100.000 U/hr for
24 hours
Ilio Femoral 1 C
Urokinase - Bolus 4400 U/kg for 10 mnt
- Maintain 2000 U/kg/hr for
12 hours
Iliofemoral 1 C
tPA 100 mg IV over 2 hours iliofemoral 1 C
Note: No evidence catheter-directed method (local) has greater benefit than
systemic intravenous
Am J Med, 2007; 120: 18-25
58. Thrombolytic Treatment
Illiofemoral DVT < 14 days
Percutaneus intervention is Performed in Catheter laboratory.
Technique :
- Popliteal vein is accessed by ultrasound guidance
- 5 Fr multisidehole catheter and wire is placed Thrombus obstruc.
- urokinase 80,000 IU / hr ( side arm ) + 80,000 /hr ( multisidehole)
- Infusion heparin following bolus 5,000 IU.
Evaluation by Contras Catheter after overnight .
.
59. Temporary Vena Cava Filter (VCF)
Indication : - DVT + Recurrent Pulmonary Embolism despite adequate
anticoagulation
- Contraindication for anticoagulant in Proximal DVT
progress to illiac vein
- After pulmonary embolectomy
- Floating Thrombus in inferior vena cava
VCF Performed in Catheter laboratory
61. Mr. An 60 Yo
- Right leg swelling, pain and warm
continuously causing difficult to walk since
5 days ago.
- 6 days ago he’s just returned from America
by plane for 24 hours and sleep soundly due
to drinking tranquilizers.
- Denied limb trauma history
62. Mr.An 60 Yo
- Sweeling on right thigh to calf, pitting
edema with diameter 4,5 cm greater thanleft
leg, felt warm and reddish.
- Homans’ Sign positive
Wells’ Score
What next???
WD/Suspect DVT
63.
64. Wells Score
Clincal Features Score Score
- Active cancer 1
- Paralysis, recent plaster cast 1
- Recent immobilisation or surgery 1
- Tenderness along entire deep vein system 1
- Swelling of entire leg 1
- > 3 cm difference in calf circumference compared
with other leg 1
- Pitting oedema 1
- Collateral superficial veins 1
- Alternative diagnosis as likely as DVT -2
High probability > 3
Moderate probability 1-2
Low Probability < 0 Interobserver reliability kappa 0.85
The prevalence of disease in each pre-test category was 85,33 and 5 % for the
high, moderate,and low probability groups, respectively.
Wells PS et al.
Lancet 1997 ; 350 : 1795-8
-
-
1
-
1
1
1
-
4
-
65. Mr.An 60 yo
High probability
Wells’ Score
What next
WD/Suspect DVT
What next
Ultrasound