Deep Vein Thrombosis
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+ Deep Vein Thrombosis Common, Preventable, and potentially Fatal
description
Deep Vein Thrombosis. Common, Preventable, and potentially Fatal. Disclaimer. Who am I. W. Robert Leeper, MD PGY IV – General Surgery and Intensive Care Medicine Schulich School of Medicine and Dentistry University of Western Ontario. Why am I giving this talk?. - PowerPoint PPT Presentation
Transcript of Deep Vein Thrombosis
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Deep Vein ThrombosisCommon, Preventable, and potentially Fatal
+Disclaimer
Who am IW. Robert Leeper, MDPGY IV – General Surgery and Intensive Care
MedicineSchulich School of Medicine and DentistryUniversity of Western Ontario
Why am I giving this talk?1) My research is in DVT and PE prevention2) It’s the last talk of the day and they heard I was ‘energetic’3) I’m a resident so I’m very, very cheap
+Overview
What IS a DVT/PE and WHY do I care? When should I SUSPECT a DVT/PE? How do I DIAGNOSE a DVT/PE? How do I PREVENT a DVT/PE? How do I TREAT a DVT/PE?
+What is a DVT/PE and why do I care?
Etiology = Virchow’s Triad: Circulatory Stasis Intimal Injury Hypercoagulability
Definition: A blood clot forming in a “deep” vein Usually lower extremity
+What is a DVT/PE and why do I care? Pulmonary Embolism:
A blood clot that formed in a “deep” vein and then “embolized” back to the heart/lungs
Commonly cited cause of the “late” trauma death
+What is a DVT/PE and why do I care?
+When should I SUSPECT a DVT/PE?
First and foremost…….. BE VERY, VERY SUSPICIOUS!!!!
+When should I SUSPECT a DVT/PE?
Incidence < 5% overall
High Risk Injuries Head Injury (44%) Lower Limb # (52%) Pelvic # (37%) Spinal Cord Injury (15%)
LHSC Data (2002 – 2007)
High Risk Event Major OR < 4h (67%) SCD Contraindicated (74%) Prolonged Immobilization (93%) Missed doses of LMWH (100%)
Humphrey, Parry, Girotti, Gray. Unpublished Data – Presented at TAC 2007
+When should I SUSPECT a DVT/PE?
Incidence 5 – 10 % overall
High Risk Injuries Spinal Cord Injury (LEVEL
I) Lower Limb # (LEVEL II) Pelvic # (LEVEL II) Head Injury (LEVEL II)
EAST Practice Guidelines High Risk Factors
Older age (LEVEL II) Higher ISS (LEVEL II) Blood Transfusions (LEVEL II)
Rogers et al. Management of Venous Thromboembolism in Trauma Patients. J Trauma. 53(1):142-164, July 2002.
+How do I DIAGNOSE a DVT/PE?
Clinical Swollen, Painful, Erythematous
Extremity SOB, pleuritic pain, tachypneia, hypoxia SUDDEN COLLAPSE Laboratory D-Dimer Blood gas, EKG, CXR
Definitive US leg veins (9 to 5 test) VQ Scan or CT PE study (24/7
test)
+How do I DIAGNOSE a DVT/PE?
Doppler US in ALL symptomatic patients Screening US in HIGH RISK patients
LHSC Practice
Doppler US in ALL symptomatic patients (LEVEL I) Screening US in HIGH RISK patients (LEVEL III)
EAST Practice Guidelines
+How do I PREVENT a DVT/PE?
Prevention Strategies Early Ambulation Prophylactic Anticoagulation Mechanical Compression Devices IVC Filters
+How do I PREVENT a DVT/PE?
Early Ambulation No debate on this topic Level I evidence Multiple benefits beyond
DVT/PE prevention Easier said than done ?
+How do I PREVENT a DVT/PE?
Prophylactic Anticoagulation Typically LMWH
Dalteparin 5000 units sc daily
LHSC Practice LMWH for ALL eligible patients LMWH given throughout hospital stay
+How do I PREVENT a DVT/PE?
EAST Guidelines LMWH for specific patients (LEVEL II)(lower extremity #, pelvic #, SCI…)
LMWH for ISS > 9 (LEVEL III)
LMWH specifically contraindicated with intracranial bleeding or epidural catheter (LEVEL III)
Prophylactic Anticoagulation
+How do I PREVENT a DVT/PE?
Mechanical Compression Devices (MCD) Preferred method if LMWH is contraindicated
LHSC Practice MCD for ALL eligible patients
EAST Guidelines MCD may not reduce rates of DVT/PE
(LEVEL II) MCD may be indicated for SCI patients
(LEVEL III)
+How do I PREVENT a DVT/PE?IVC Filters
What are they?
How do they work?
When should we use them?
+How do I PREVENT/TREAT a DVT/PE? IVC Filters
Traditional Indications (LEVEL 1) Known DVT + contraindication to anticoagulation Recurrent PE while on anticoagulation
“Extended” Indications (LEVEL II) Free floating clot in iliac/IVC Following ‘massive’ PE
“Prophylactic” Indications (LEVEL III) Any high risk injury type + contraindication to anticoagulation(SCI, Pelvic #, Extremity #, Severe closed head…)
+How do I PREVENT/TREAT a DVT/PE?
IVC Filters – LHSC Experience
2000 – 2008 n = 27 filters Very selective utilization 85% retrieval rate Impressive retrieval rate
Leeper, Gray, Kribs, Parry. Unpublished Data – Presented at ATS/TAC 2009
+How do I PREVENT/TREAT a DVT/PE?
IVC Filters – LHSC Experience
Leeper, Gray, Kribs, Parry. Unpublished Data – Presented at ATS/TAC 2009
Indication for Placement of IVCF in
Trauma Patients
3 (11%)
10 (37%)
14 (52%)
VTE Prophylaxis
DVT(contraindication for
anticoagulation) (contraindication for anticoagulation)
PE
N = 27
+How do I PREVENT/TREAT a DVT/PE?
IVC Filters – LHSC Experience
Leeper, Gray, Kribs, Parry. Unpublished Data – Presented at ATS/TAC 2009
Figure 2 – Indication for Retrieval/Non Retrieval of
IVCF23 (85%)
Successfully retrieved
2 (7%)
2 (7%)
Irretrievable due to trapped
clot Died of
Injuries
Loss to Follow Up Rate = 0%
N = 27
+How do I PREVENT/TREAT a DVT/PE? Treatment of Known DVT/PE
Full Dose Anticoagulation IV Heparin infusion Fragmin at HIGH dose (200 u/kg)
IVC Filter If anticoagulation contraindicated
Thrombolytics vs Surgical Embolectomy Indicated for MASSIVE pulmonary embolism
+Summary – DVT/PE
DVT and PE in Trauma Patients Maintain a HIGH INDEX of suspicion Maintain a LOW THRESHOLD to investigate Prevention >>> Cure
+Thank you
Dr. W. Robert Leeper MDGeneral Surgery and Critical Care Medicine - PGY IV
Schulich School of Medicine and DentistryThe University of Western Ontario
