Flashcards in Deep vein thrombosis Deck (21)
1
Risk factors
Strong
medical hospitalisation within the past 2 months
major surgery within 3 months
active cancer
lower-extremity trauma
increasing age
pregnancy
obesity
factor V Leiden
prothrombin gene mutation G20210A
protein C or S deficiency
antithrombin deficiency
antiphospholipid antibody syndrome
medical comorbidity
recent long-distance air travel
use of specific drugs->OCP
nephrotic syndrome
family hx
2
Signs
Calf warmth, swelling, tender
Mild fever
Pitting edema
Homan's sign->should not be tested as can dislodge a clot
3
History- important
Symptoms
Recent surgery, presence of an active cancer, lower-extremity trauma, recent hospitalisation, recent immobility, and presence of underlying chronic medical illness. Family history of venous thrombosis or PE
current pregnancy, obesity, factor V Leiden mutation, prothrombin gene mutation G20210A, protein C or S deficiency, antithrombin (AT) deficiency, antiphospholipid antibody syndrome, acute medical comorbidity (especially those associated with inflammation, infection, and immobility), recent long-distance air travel, and use of certain drugs including oestrogen- or third-generation progestogen-containing oral contraceptives, tamoxifen, raloxifen, thalidomide, or erythropoietin
4
Physical examination
Wells score assessment
5
Wells score
Wells' criteria:
Active cancer (any treatment within past 6 months): 1 point
Calf swelling where affected calf circumference measures >3 cm more than the other calf (measured 10 cm below tibial tuberosity): 1 point
Prominent superficial veins (non-varicose): 1 point
Pitting oedema (confined to symptomatic leg): 1 point
Swelling of entire leg: 1 point
Localised pain along distribution of deep venous system: 1 point
Paralysis, paresis, or recent cast immobilisation of lower extremities: 1 point
Recent bed rest for >3 days or major surgery requiring regional or general anaesthetic within past 12 weeks: 1 point
Previous history of DVT or PE: 1 point
Alternative diagnosis at least as probable: subtract 2 points.
6
Interpreting wells
>2 points->diagnosis likely
7
Occurence of DVT
1 in 1000 live adults
8
Percentage of people who experience post-thrombotic syndrome after DVT
60%
9
Investigations
Well's
D-dimer
Venous duplex USS
INT/aPTT
UEC
LFTs
FBC
CT abdomen pelvis if filling defect
Thrombophilia screen->no predisposing, recurrent, family history
10
Tests in thrombophilia screen
Anti-cardiolipin
Lupus anticoagulant
Beta-2 glycoprotein
Protein C and S
Factor V leiden
Prothrombin
Antithrombin
11
Management
Graduated compression stocking
Mobilisation
Enoxaparin
Warfarin
12
Duration of warfarin
Clinical situation
Duration
VTE provoked by a transient major risk factor
3 months
unprovoked distal DVT
3 months
first unprovoked proximal DVT or PE
6 months
first unprovoked VTE plus:
active cancer
multiple thrombophilias
antiphospholipid antibody syndrome
indefinite
recurrent unprovoked VTE
indefinite
13
When would you consider IVC filter
When active bleeding
Anticoagulants fail
14
Overview of approach to DVT prophylaxis
Reduce risks
Early mobilisation
Fluids
Pharmacotherapy
Mechanical
Analgesia
Physiotherapy
15
Considerations for DVT prophylaxis
1. Surgery required
2. Other medical conditions which can +risk
3. Contraindications
4. Mechanical
16
Surgical risk stratification general
1. Any surgical procedure
2. especially abdominal, pelvic, thoracic or orthopaedic surgery.
3. Major joint surgery and curative surgery for cancer carry very high VTE risk
4. leg injury requiring surgery or prolonged immobilisation
5. prolonged surgery and/or prolonged immobilisation.
17
Medical conditions that can +risk
Chronic medical conditions
Paresis
+Age (low risk)
OCP/HRT
Varicose veins (low risk)
Previous VTE
Thrombophilia
Malignancy
Trauma/surgery
Indwelling catheter
DM
Pregnancy/Peripartum
Extended travel
Myeloproliferative disease
CCF, COPD
IBD, Obesity (low risk)
18
Contraindications to prophylaxis
Inherited/acquired bleeding disorder,
coagulopathy, DIC-->
Need INR, PTT
PLT disorders
19
Differential diagnosis
Cellulitis
Calf muscle tear
Calf muscle hematoma
Baker's cyst
Pelvic/thigh mass/tumour compressing venous outflow from the leg
Thrombophlebitis
Compartment syndrome
20
Differentiating features in cellulitis
1. Patients with cellulitis usually manifest redness, heat, and swelling in the dermis of the affected leg. The affected area is likely to be smaller than in DVT (which may involve the entire foot, calf, or thigh), but the signs more pronounced.
2. The demarcation of the skin margins more defined
3. Portal of infection entry may be identified. [71]
4. Fever and prior history of cellulitis is common.
May occur with a concurrent DVT
21