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PE, DVT, and Thee

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Title: PE, DVT, and Thee


1
PE, DVT, and Thee
  • By
  • Paul Rega, MD, FACEP
  • OMNI Health Services
  • (You knowthe docs
  • who work the ER)

2
VTE
  • Definition Spectrum of diseases that includes
    DVT and PE

3
Introduction
  • 2 million diagnosed with DVT annually
  • Maybe 80-117/100,000 persons occur annually.
  • 900/100,000 by age 85
  • 1 person in 20 will develop a DVT in his/her
    lifetime.
  • 600,000 hospitalizations per year occur for DVT
    in the United States.
  • In hospitalized patients, the incidence of venous
    thrombosis is considerably higher and varies from
    20-70.

4
More Introduction
  • 600,000 diagnosed with PE annually
  • Death from DVT is attributed to massive PE
  • Causes 200,000 deaths annually in the United
    States.
  • Prospective studies in patients with proven DVT
    but without any signs or symptoms to suggest PE
    find that roughly half of these "asymptomatic"
    patients have experienced undiagnosed PE.

5
Peripheral
6
Interesting
  • Prospective studies show that in the absence of
    prophylaxis acute DVT may be demonstrated in any
    of the following
  • General medical patients placed at bed rest for a
    week (10-13)
  • Patients in medical intensive care units (29-33)
  • Patients with pulmonary disease kept in bed for 3
    or more days (20-26)
  • Patients admitted to a coronary care unit after
    myocardial infarction (27-33)
  • Patients who are asymptomatic after coronary
    artery bypass graft (48)

7
What is the Virchow Triad?
  • Not a type of Kishka
  • Blood sausage from Poland
  • For you WASPS out there.

8
Virchow Triad
  • All recognized risk factors for VTE arise from
    the 3 underlying components of the Virchow triad
  • Venous stasis,
  • Hypercoagulability, and
  • Vessel intimal injury.

9
Risk Factors
  • General
  • Age
  • Immobilization longer than 3 days
  • Pregnancy and the postpartum period
  • Impaired fibrinolysis
  • Major surgery in previous 4 weeks
  • General anesthesia (500x)
  • Impaired fibrinolysis
  • Long plane or car trips (gt4 h) in previous 4
    weeks
  • Obesity?
  • Trauma
  • Multiple trauma
  • CNS/spinal cord injury
  • 40 in post-op
  • Burns
  • Lower extremity fractures
  • Medical
  • Cancer
  • Previous DVT
  • 5x
  • Stroke
  • 50 in 5d post-stroke
  • Acute myocardial infarction (AMI)
  • Congestive heart failure (CHF)
  • Sepsis
  • Nephrotic syndrome
  • Ulcerative colitis
  • Fibrinogen/VIII up
  • Antithrombin III down
  • Hyperlipidemia

10
Risk Factors (continued)
  • Hematologic
  • Polycythemia rubra vera
  • Thrombocytosis
  • Inherited disorders of coagulation/fibrinolysis
  • Antithrombin III (anticoag) deficiency
  • Liver disease
  • Protein C (anticoag) deficiency
  • Natural/acquired
  • Protein S (anticoag) deficiency
  • Prothrombin 20210A mutation
  • Factor V Leyden
  • 7 of general population
  • 50 of idiopathic DVT
  • Dysfibrinogenemias and disorders of plasminogen
    activation
  • Type A in reproductive women
  • Vasculitis
  • Systemic lupus erythematosus (SLE) and the lupus
    anticoagulant
  • 9
  • Behçet syndrome
  • Homocystinuria
  • Drugs/medications
  • Intravenous drug abuse
  • Oral contraceptives
  • Impaired fibrinolysis
  • 3-12 x higher
  • Estrogens
  • Heparin-induced thrombocytopenia
  • ChemoRx
  • Reduce anticoag/increase procoag

11
What about
  • The upper extremity (UE)?

12
Upper Extremity DVT
  • Growing incidence
  • Due to indwelling catheters and dialysis .
  • PE from UE DVT as frequent as PE from LE DVT.
  • Sounds like a cryptic message from al-Qaeda,
    doesnt it?
  • 512 patients with arm DVT (Chest.
    2008133143-8.)
  • 196 patients (38) had cancer and 228 patients
    (45) had catheter-related DVT.
  • Patients with arm DVT have less often clinically
    overt PE than those with lower-limb DVT, but
    their 3-month outcome is similar.
  • Among patients with arm DVT, those with cancer
    have the worse outcome.

13
What are the signs and symptoms of DVT?
  • Lower extremity (LE)
  • Proximal
  • Distal
  • Most clinical PEs come from
  • Popliteal v.
  • Femoral v.
  • Iliac v.

14
A Dilemma
  • Even when a patient has a swollen, painful,
    congested leg that appears to be clinically
    obvious DVT, the chance that DVT is the correct
    diagnosis is only 50.
  • Most cases of DVT lack classic signs or symptoms
  • Thus, diagnostic tests must be performed whenever
    the diagnosis of DVT is being considered.

15
Propagation
  • 10-30 of distal clots propagate to proximal
    legs.
  • The single largest autopsy series ever performed
    to specifically to look for the source of fatal
    PE was performed by Havig in 1977, who found that
    one third of the fatal emboli arose directly from
    the calf veins.

16
Wells Clinical model for predicting pretest
probability of deep-vein thrombosis
  • Active CA (Rx ongoing, given within previous 6
    mos. or palliative) 1
  • Paralysis, paresis, or recent plaster
    immobilization of lower limbs 1
  • Recently bedridden gt3d or major surgery within
    previous 12 wk requiring general or regional
    anesthesia
    1
  • Localized tenderness along deep venous system
    1
  • Swelling of entire leg
    1
  • Calf swelling gt3cm more than uninvolved leg (10
    cm below tibial tuberosity) 1
  • Pitting edema confined to symptomatic leg 1
  • Collateral superficial veins (nonvaricose) 1
  • Previously documented DVT 1
  • Alternative diagnosis at least as likely as DVT
    -2

Score 2 or more DVT probability likely Score
lt 2 DVT probability unlikely.
High probability 3 (gt65) Moderate
probability 1-2 Low probability 0 or less (lt10)
17
Case 1
  • 35 YO Female
  • Left leg pain
  • What do you want to know?

18
Case 1
  • Present Hx
  • Past Hx
  • Family Hx
  • Medications

19
Case 1 The Exam
  • Examining the leg

20
Case 1
  • Probability?

21
Case 2
  • 85 YO Male
  • Deep ache in right leg just above ankle.
  • What do you want to know?

22
Case 2
  • Probability?

23
Case 3
  • 50 YO Female
  • Pain and swelling left leg.
  • What do you want to know?

24
Case 3
  • Probability?

25
Now the test
26
In the days of King ArthurIPG
  • Records changes in blood volume of an extremity,
    which are directly related to venous outflow.
  • Sensitive and specific for proximal vein
    thrombosis
  • Insensitive for calf vein thrombosis.
  • Insensitive for UE DVT

27
IPG
  • Noninvasive
  • Inexpensive
  • Safe
  • No radiation
  • Portable
  • Accurate
  • Proximal DVT
  • Recurrent DVT
  • Operator dependent
  • Insensitive (false neg.)
  • Calf DVT
  • Non-obstructing thrombi
  • Nonspecific (false pos.)
  • Increased intra-abdominal pressure
  • Increased CVP
  • Decreased blood flow to legs
  • Nonthrombotic venous outflow obstruction

28
Venogram
  • Sensitive
  • 100 (Proximal)
  • Specific
  • 100 (Proximal)
  • Acute vs Chronic
  • Less operator dependent
  • Most accurate for calf DVT
  • Invasive
  • Expensive
  • Not portable
  • Contraindications
  • Renal insufficiency
  • Contrast allergy
  • Painful
  • Cause DVT

29
Venogram
  • Gold standard?
  • Radiologists
  • Uncomfortable/unwilling
  • With non-expert radiologists
  • Up to 30 are technically inadequate
  • Phlebitis
  • Allergic reaction
  • Largely replaced by Doppler US.

30
US
  • Compressibility of veins
  • Doppler
  • Flow characteristics
  • Sensitivity of duplex ultrasonography
  • Proximal vein DVT 97
  • Calf vein DVT 73
  • Specific
  • 95

31
US
  • Noninvasive
  • Safe
  • Portable
  • Relatively inexpensive
  • Available
  • No radiation
  • UE DVT
  • Operator dependent
  • Less accurate
  • Chronic DVT
  • Calf DVT
  • Pelvic DVT
  • Difficult
  • Obesity
  • Edema

32
US
  • In U.S., 500,000 patients evaluated for DVT
  • 80 normal at 1st US
  • Only 2 abnormal 5-7 days later
  • Spending a lot of when most of the tests
    come back negative.

33
US
  • Negative at Day 0
  • 50 Positive at Day 1
  • 50 Positive by day 7

34
MRI
  • In limited studies, accuracy approaches that of
    venography.
  • The diagnostic test of choice for suspected iliac
    vein or inferior vena caval thrombosis when CT
    venography is contraindicated or technically
    inadequate.
  • In the second and third trimester of pregnancy,
    MRI is more accurate than duplex ultrasonography
    because the gravid uterus alters Doppler venous
    flow characteristics.
  • Said to be as sensitive as US in detecting calf
    and pelvic DVTs.

35
MRI
  • Sensitive
  • Specific
  • Safe
  • Pelvic/IVC DVT
  • No radiation
  • Acute vs chronic
  • Claustrophobic
  • Expensive
  • Not portable
  • Metallic devices
  • Insensitive
  • Calf DVT

36
D-Dimer
  • Fibrin degradation product
  • Value increases with clots, surgery, trauma, CA,
    infection, Gabby Hays.
  • Many types
  • Most accurate Quantitative
  • ELISA (Enzyme-linked immunosorbent assay)
  • STA Liatest immunoturbidimetric D-dimer assay
  • Cut-off 0.21 µg/mL
  • Low risk patients normal D-dimer lt1
    probability of DVT.
  • D-dimer Not to be used alone to r/o DVT in
    patients with moderate or high probability of DVT
  • Sensitivity is always lower for calf DVT

37
Bottom Line
  • A positive D-dimer needs further testing.

38
Determination of pretest probability of DVT
DVT unlikely (score 1)
DVT likely (score gt1)
Good D-Dimer test
Good D-Dimer test
_
_


Ultrasound
No DVT
Ultrasound
Ultrasound
_
_

_


Treat with anticoagulants
Repeat US in 1 week
Treat with anticoagulants
No DVT
No DVT
_

No DVT
One Guideline
39
Treatment
40
Importance of Proper/Prompt DVT Therapy
  • Decreases risk of recurrent DVT to 5
  • Decreases risk of fatal PE to lt1

41
Leg DVT
  • Heparin/Lovenox OK
  • Fibrinolysis
  • Unclear
  • If Limb-threatening
  • Remember Thrombolytic therapy increases the
    risk of major bleeding 1.5-fold to threefold in
    patients with acute venous thromboembolism

42
Heparin
  • Binds to Antithrombin
  • Accelerates ability of Antithrombin to inactivate
    Thrombin, factor Xa, Factor IXa.
  • 1/2 life 60
  • Bioavailability
  • Variable due to protein binding.
  • Bleeding complication
  • The risk of bleeding associated with IV
    unfractionated heparin (UFH) in patients with
    acute venous thromboembolism is lt 3 in recent
    trials.
  • Bleeding risk may increase with increasing
    heparin dosages and age (gt 70 years).

43
Low-Molecular-Weight Heparin
  • Derived from heparin
  • Result of depolymerization
  • 1/3rd the size of heparin
  • Research on thousands
  • Safe
  • Effective
  • Convenient

44
LMWH
  • Enoxaparin (Lovenox), dalteparin (Fragmin), and
    tinzaparin (Innohep) have received US Food and
    Drug Administration (FDA) approval for the
    treatment of DVT in the United States.
  • Enoxaparin Approved for inpatient and outpatient
    treatment of DVT.
  • No monitoring
  • gt90 bioavailable
  • Minimal protein binding
  • Levels are predictable
  • No heparin-induced thrombocytopenia (1)
  • No anti-heparin antibodies
  • In plasma for 12-16h
  • Allows for BID dosing
  • Associated with less major bleeding compared with
    UFH in acute venous thromboembolism.

45
Fondaparinux (Arixtra)
  • New
  • A synthetic pentasaccharide
  • Catalyzes the inhibition of factor Xa, but not
    thrombin, in an antithrombin-dependent fashion
  • Binds only to antithrombin
  • therefore, HIT and osteoporosis are unlikely to
    occur.
  • Excellent bioavailability when administered
    subcutaneously
  • Has a longer half-life than LMWHs.
  • Given once daily by subcutaneous injection in
    fixed doses, without anticoagulant monitoring.

46
Direct Thrombin Inhibitors
  • Hirudin
  • Bivalirudin
  • Argatroban
  • Melagatran
  • Parenteral

47
Greenfield Filter
  • When anticoagulation has failed or
  • Risk of serious hemorrhage
  • May double risk of recurrent DVT

48
Proven Clinically Significant DVT
Any reason for hospitalization ? Comorbidity? Comp
liance concerns? Logistical issues?
Yes
No
  • LMWH
  • Coumadin 5mg q day
  • VNA for BID
  • injections
  • Evaluate
  • discontinuation of LMWH
  • 5) Evaluate q 5-7d

Hospitalize
49
Central
50
PE
  • 300,000/annually
  • 2 die within 1st day
  • 10 get recurrent PE
  • Death rate 45

51
PE A Difficult Diagnosis
  • 2 Studies
  • Univ. of Toronto
  • 44 die from PE
  • 30 (68) diagnosed at autopsy
  • Henry Ford
  • 20 die from PE
  • 14 (70) diagnosed at autopsy
  • 2/3rd of patients with proven PE have no DVT
    symptoms, and
  • 1/3rd of patients Impossible to find the
    original site of DVT without an autopsy.

52
What are the SS of PE?
  • Come on. What are the signs and symptoms of PE?

53
A Conundrum
  • Hemoptysis, dyspnea, chest pain occur in fewer
    than 20 of patients in whom the diagnosis of PE
    is made
  • Most patients with those symptoms are found to
    have some etiology other than PE to account for
    them.
  • Of patients who go on to die from massive PE
  • 60 have dyspnea
  • 17 have chest pain
  • 3 have hemoptysis
  • PE has been diagnosed in 21 of young, active
    patients who come to the ED complaining only of
    pleuritic chest pain.

54
Signs Seen in Massive PE
  • 96 Tachypnea (respiratory rate gt16/min)
  • 58 Rales
  • 44 Tachycardia (heart rate gt100/min)
  • 43 Fever (temperature gt37.8 C)
  • 36 Diaphoresis
  • 32 Clinical signs and symptoms suggesting
    thrombophlebitis
  • 24 Lower extremity edema
  • 23 Cardiac murmur
  • 19 Cyanosis

55
Atypical Presentations
  • Patients with PE may present with atypical
    symptoms, where strong suspicion in a high-risk
    patient often leads to consideration of PE in the
    differential diagnosis
  • Seizures
  • Syncope
  • Abdominal pain
  • Fever
  • Productive cough
  • Wheezing
  • Decreasing level of consciousness
  • New onset of atrial fibrillation

56
Wells Clinical Prediction Rule for PE
  • Clinical symptoms of DVT
    3
  • Other dx less likely than PE
    3
  • Heart rate gt100 bpm
    1.5
  • Immobilization/surgery within past 4 wks 1.5
  • Previous DVT/PE
    1.5
  • Hemoptysis
    1
  • Malignancy
    1

Risk Score gt 6 High risk (78.4) 2-6
Moderate risk (27.8) lt2 Low risk (3.4).
57
What non-imaging tests can help you?
  • Come on What non-imaging tests can help you?

58
What tests?
  • EKG?
  • Nonspecific changes or tachycardia usually
  • S1-Q3-T3 pattern In only 20 of patients with
    proven PE.
  • ABGs?
  • Nonspecific
  • Moderately sensitive
  • pO2 may be normal with minor PE
  • ? pO2 and ?pCO2
  • Seen in conditions other than PE
  • D-dimers?
  • Depends
  • Others?

59
CXR?
  • What would you expect to find?

60
CXR
  • Virtually always normal.
  • Rarely the Westermark sign
  • A dilatation of the pulmonary vessels proximal to
    an embolism along with collapse of distal
    vessels, sometimes with a sharp cutoff.
  • Over time, an initially normal CXR often begins
    to show atelectasis, which may progress to cause
    a small pleural effusion and an elevated
    hemidiaphragm.
  • After 24-72 hours, one third of patients with
    proven PE develop focal infiltrates that are
    indistinguishable from an infectious pneumonia.
  • A rare late finding of pulmonary infarction
  • The Hampton hump, a triangular or rounded
    pleural-based infiltrate with the apex pointed
    toward the hilum, frequently located adjacent to
    the diaphragm.

61
V-Q Scan
Scan
Clinical Probability
80 100 20 - 79
0 - 19
High 82-99
78-94 21-86
Intermediate 49-80 22-34
8-27
Low 16-68
11-22 1-11
Normal 0-52
2-16 0-9
Bottom line Only use scans with high
probability or normal for clinical
decision-making. N.B. Only 40 of scans in PE
patients are high probability.
62
MDCTA
  • High-resolution multidetector computed
    tomographic angiography
  • Has sensitivity and specificity comparable to
    that of contrast pulmonary angiography
  • Accepted both as the preferred primary diagnostic
    modality and as the criterion standard for making
    or excluding the diagnosis of pulmonary embolism.
  • Caution Multiple small emboli that have lodged
    in distal vessels
  • Overall negative predictive value of MDCTA for
    pulmonary embolism is greater than 99.
  • Future Simultaneous MDCTA Below-the-pelvis CT
    venography without added contrast

63
Pulmonary Angiography
  • Complications 3-4
  • Arrhythmias, cardiac perforation, cardiac arrest,
    hypersensitivity
  • Gold standard
  • A positive pulmonary angiogram provides virtually
    100 certainty that an obstruction to pulmonary
    arterial blood flow does exist.
  • A negative pulmonary angiogram provides greater
    than 90 certainty in the exclusion of PE.
  • Being replaced by MDCTA

64
Transthoracic Echocardiography (TTE)
  • TTE alone is not sensitive or specific enough for
    detecting PE
  • New study The ratio of right ventricular to
    left ventricular (RV/LV) end diastolic dimension
    was the most accurate predictor for PE, with a
    sensitivity and specificity of 66 and 77,
    respectively.
  • Might lead cardiologist in the right direction
  • Echocardiography 2008 25 584-590

65
SS of PE
SS of PE
Pre-test PE probability score
CT pulmonary angiography
Negative
Positive
Treat PE
Doppler US of legs
Negative
Positive
Treat VTE
Pre-test PE probability score
Intermediate
Low
High
D-dimer or serial US
Angiography
Negative
Positive
Treat PE
Follow-up for alternative dx
Diagnosing PE with CT (adapted from Am Fam Phys
2004 69 12)
66
SS of PE
SS of PE
Pre-test PE probability score
V-Q Scan
Normal
High Probability
Low/Intermediate Probability
Follow-up for alternative dx
Pre-test PE probability score
Follow US protocol from prior slide
Intermediate
Low
High
Angiography
Negative
Positive
Treat PE
Follow-up for alternative dx
Diagnosing PE with V/Q Scanning (adapted from Am
Fam Phys 2004 69 12)
67
Case 1
  • 35 YO Female
  • Mom 2 days ago
  • I feel a little shaky, a little short of
    breath.

68
Case 1
  • What do you want to know?

69
Case 1
  • What do you want to do?

70
Case 2
  • 85 YO Male
  • Admitted for cellulitis of the left leg
  • My damn heart is doing flippity-flops, Cutie.

71
Case 2
  • What do you want to know?

72
Case 2
  • What do you want to do?

73
Case 3
  • 50 YO Female
  • Being worked up for spread of breast CA.
  • I cant breathe all of a sudden.

74
Case 3
  • What do you want to know?

75
Case 3
  • What do you want to do?

76
Treatment
77
The Drugs
  • UFH
  • LMWH
  • Arixtra

78
Heparin (UFH)
  • 5000U or 80 U/kg IV to start
  • Heparin-Induced Thrombocytopenia (HIT)
  • 9/332 (2.7)
  • Consider
  • Thrombotic syndrome
  • Platelets fall gt50
  • Especially if treated within 2 weeks
  • Usually between 5-14 days of heparin initiation
  • May not be on heparin at the time
  • Bleeding
  • The risk of major bleeding associated with IV
    unfractionated heparin (UFH) in patients with
    acute venous thromboembolism is lt 3 in recent
    trials. This bleeding risk may increase with
    increasing heparin dosages and age (gt 70 years).
  • 35/1853 (1.9)

79
Suspected or Confirmed HIT? What to do?
  • An alternative, nonheparin anticoagulant
  • Danaparoid
  • Lepirudin (Refludan)
  • Argatroban
  • Fondaparinux (Arixtra) or
  • Bivalirudin (Angiomax) over the further use of
    unfractionated heparin (UFH) or
    low-molecular-weight heparin (LMWH) therapy or
    initiation/continuation of vitamin K antagonists
    (VKAs)
  • For patients receiving Coumadin at the time of
    diagnosis of HIT, vitamin K (10 mg po or 5 to 10
    mg IV) is recommended
  • When to re-start? Controversial.

80
LMWH Dosages
  • Lovenox 1 mg/kg q 12h or 1.5 mg/kg/d SC
  • Max. 180 mg/d
  • Fragmin 100U/kg q 12h or 200 U/kg/d SC
  • Max. 18,000U/d
  • Innohep 175U/kg/d SC
  • Max. 18,000U/d

81
Fondaparinux (Arixtra)
  • A synthetic pentasaccharide
  • Catalyzes the inhibition of factor Xa, but not
    thrombin, in an antithrombin-dependent fashion
  • Binds only to antithrombin
  • therefore, HIT and osteoporosis are unlikely to
    occur.
  • Excellent bioavailability when administered
    subcutaneously,
  • Has a longer half-life than LMWHs.
  • Given once daily by subcutaneous injection in
    fixed doses, without anticoagulant monitoring.

82
Recent Recommendations for VTE Therapy (Confirmed)
  • Patients with objectively confirmed deep vein
    thrombosis (DVT) or pulmonary embolism (PE)
  • subcutaneous (SC) low-molecular-weight heparin
    (LMWH),
  • monitored IV, or SC unfractionated heparin (UFH),
  • unmonitored weight-based SC UFH, or
  • SC Fondaparinux
  • At least 5 days
  • With Coumadin

83
Recent Recommendations for VTE Therapy (Suspected)
  • Patients with a high clinical suspicion of DVT or
    PE
  • Treatment with anticoagulants while awaiting the
    outcome of diagnostic tests.

84
Recent Recommendations for PE Thrombolytic Therapy
  • Confirmed PE
  • Early evaluation of the risks to benefits of
    thrombolytic therapy.
  • Thrombolytic therapy increases the risk of major
    bleeding 1.5-fold to threefold in patients with
    acute venous thromboembolism
  • Hemodynamic compromise
  • Short-course thrombolytic therapy
  • Nonmassive PE
  • Use of thrombolytic therapy not recommended

85
Thrombolytics
  • Reteplase (Retavase) Preferred (fast)
  • Alteplase/t-PA (Activase) Preferred (fast)
  • Urokinase (Abbokinase)
  • Streptokinase (Kabikinase, Streptase)
  • Least desirable of the 4 Antigenic problems and
    other adverse reactions force the cessation of
    therapy in a large number of cases.
  • Total pulmonary resistance (along with pulmonary
    artery pressure and cardiac index) improved
    significantly after just 0.5 hours in the
    reteplase group as compared to 2 hours in the
    alteplase group.

86
Surgical Thromboembolectomy
  • Reserved for patients in whom fibrinolysis has
    failed or cannot be tolerated.

87
Disposition
  • PE
  • Admit
  • DVT
  • Another story

88
A Word about Special Cases
89
Pregnancy
  • Pulmonary embolism (PE) Leading cause of
    maternal mortality during pregnancy and up to 6
    weeks postpartum.
  • Most common nontraumatic cause of maternal death
    in pregnancy
  • Compared with nonpregnant women, pregnant women
    have a 5-fold increased risk for VTE.
  • Prevalence is even higher in the postpartum
    period.
  • LMWH over UFH for the prevention and treatment of
    VTE
  • Throughout pregnancy 6 weeks post-partum
  • Thrombolytics (same dosage) if condition warrants.

90
Imaging in Pregnancy
  • Helical computed axial tomographic pulmonary
    angiography (HCTPA ) vs. V/Q vs. MRI?
  • HCTPA is associated with lower radiation doses
    when compared with V/Q scanning during all
    trimesters of pregnancy.
  • MRI
  • Fetus is not exposed to ionizing radiation or
    intravenous contrast material.
  • Sensitivity and specificity of MRI have been
    reported in ranges comparable to HCTPA for the
    diagnosis of PE.
  • Disadvantages Long acquisition times, with the
    need for respiratory and cardiac gating.
  • What does X-Ray do here?????

91
Kids
  • Anticoagulant therapy with either unfractionated
    heparin (UFH) or low-molecular-weight heparin
    (LMWH)

92
In Conclusion
  • Ahhhhhhh..hhh, finally!

93
VTE Prophylaxis in Hospital
  • No to aspirin alone as thromboprophylaxis for any
    patient group
  • Mechanical methods of thromboprophylaxis OK for
    patients at high bleeding risk or possibly as an
    adjunct to anticoagulant thromboprophylaxis
  • Major general surgery, thromboprophylaxis with a
    low-molecular-weight heparin (LMWH), low-dose
    unfractionated heparin (LDUH), or Fondaparinux
  • Routine thromboprophylaxis for all patients
    undergoing major gynecologic surgery or major,
    open urologic procedures with LMWH, LDUH,
    Fondaparinux, or intermittent pneumatic
    compression (IPC).
  • Elective hip or knee arthroplasty, one of the
    following three anticoagulant agents is
    recommended LMWH, Fondaparinux, or a vitamin K
    antagonist (VKA)
  • Hip fracture surgery (HFS), the routine use of
    Fondaparinux, LMWH, a VKA or LDUH is recommended
  • All major trauma and all spinal cord injury (SCI)
    patients should receive thromboprophylaxis
  • Acute medical illness, thromboprophylaxis with
    LMWH, LDUH, or Fondaparinux is recommended
  • All ICU patients be assessed for their risk of
    VTE, and that most receive thromboprophylaxis on
    admission

94
References
  • Clinical Policy Critical Issues in the
    Evaluation and Management of Adult Patients
    Presenting with Suspected Lower-Extremity Deep
    Venous Thrombosis. Ann Emerg Med 2003 42
    124-135.
  • Bates SM, Ginsberg JS. Treatment of Deep-Vein
    Thrombosis. NEJM 2004 351 268-277.
  • Linken LA, Choi PT, et al. Clinical Impact of
    Bleeding in Patients Taking Oral Anticoagulant
    Therapy for Venous Thromboembolism. Ann Intern
    Med 2003 139 893-900.

95
References
  • Kearon C, Hirsh J. Venous Thromboembolism.
    www.acpmedicine.com/sam/chapters/ch0118.htm.
    Accessed 1/5/05.
  • Ramzl DW, Leeper KV. DVT and Pulmonary Embolism
    Diagnosis. Am Fam Physician 2004692829-2836.
  • Kyrte PA, Eichinger S. Deep Vein Thrombosis.
    Lancet 2005 365 1163-1174.
  • Ho WK, Hankey GJ, et al. Venous Thromboembolism
    Diagnosis and Management of Deep Venous
    Thrombosis. MJA 2005 182 476-481.

96
References
  • Kearon C, Ginsberg JS, et al. A randomized Trial
    for Diagnostic Strategies after Normal Proximal
    Vein Ultrasonography for Suspected Deep Venous
    Thrombosis D-Dimer Testing Compared with
    Repeated Ultrasonography. Ann Intern Med 2005
    142 490-496.
  • Scarvelis D, Wells PS. Diagnosis and Treatment
    of Deep-Vein Thrombosis. CMAJ 2006 175
    1087-1091.
  • Stein PD, Hull RD, et al. Tracking the Uptake of
    Evidence (Two decades of hospital practice Trends
    for diagnosing deep vein thrombosis and pulmonary
    embolism). Arch Intern Med 2003 163 1213-1219.

97
References
  • Schreiber D. Deep Venous Thrombosis and
    Thrombophlebitis http//www.emedicine.com/emerg/to
    pic122.htm. Accessed 6/14/08.
  • Feied C. Deep Venous Thrombosis
    http//www.emedicine.com/MED/topic2785.htm.
    Accessed 6/14/08.
  • Muñoz FJ, Mismetti P, Poggio R, et al. Clinical
    outcome of patients with upper-extremity deep
    vein thrombosis results from the RIETE Registry.
    Chest. 2008 Jan133(1)143-8.

98
References
  • Stevens S, et al. Withholding Anticoagulation
    after a Negative Result on Duplex Ultrasonography
    for Suspected Symptomatic deep Venous Thrombosis.
    Ann Intern Med 2004.
  • Controversies in Pulmonary Embolism and Deep
    Venous Thrombosis. Amer Acad Fam Physicians,
    1999.
  • Anand S, et al. The Rational Clinical
    Examination Does This Patient Have Deep Venous
    Thrombosis? JAMA 1998.

99
References
  • Shannon M. Bates, Ian A. Greer, Ingrid Pabinger,
    et al. Venous Thromboembolism, Thrombophilia,
    Antithrombotic Therapy, and Pregnancy American
    College of Chest Physicians Evidence-Based
    Clinical Practice Guidelines (8th Edition).
    Chest Jun 2008 844S886S.
  • Paul Monagle, Elizabeth Chalmers, Anthony Chan,
    et al. Antithrombotic Therapy in Neonates and
    Children American College of Chest Physicians
    Evidence-Based Clinical Practice Guidelines (8th
    Edition). Chest Jun 2008 887S968S.
  • Clive Kearon, Susan R. Kahn, Giancarlo Agnelli,
    et al. Antithrombotic Therapy for Venous
    Thromboembolic Disease American College of Chest
    Physicians Evidence-Based Clinical Practice
    Guidelines (8th Edition). Chest Jun 2008
    454S545S.

100
References
  • William H. Geerts, David Bergqvist, Graham F.
    Pineo, et al. Prevention of Venous
    Thromboembolism American College of Chest
    Physicians Evidence-Based Clinical Practice
    Guidelines (8th Edition). Chest Jun 2008
    381S453S.
  • Theodore E. Warkentin, Andreas Greinacher,
    Andreas Koster, et al. Treatment and Prevention
    of Heparin-Induced Thrombocytopenia American
    College of Chest Physicians Evidence-Based
    Clinical Practice Guidelines (8th Edition).
    Chest Jun 2008 340S380S.
  • Sam Schulman, Rebecca J. Beyth, Clive Kearon, et
    al. Hemorrhagic Complications of Anticoagulant
    and Thrombolytic Treatment American College of
    Chest Physicians Evidence-Based Clinical Practice
    Guidelines (8th Edition). Chest Jun 2008
    257S298S.

101
References
  • Feied CF. Pulmonary Embolism. http//www.emedicine
    .com/emerg/topic490.htm/ Accessed, 6/29/08.
  • Jack Hirsh, MD, FCCP Kenneth A. Bauer, MD Maria
    B. Donati, MD, PhD, et al. Parenteral
    Anticoagulants. American College of Chest
    Physicians Evidence-Based Clinical Practice
    Guidelines (8th Edition). Chest. 2008
    133141S-159.
  • Sharma S. Pulmonary Embolism http//www.emedicine.
    com/med/TOPIC1958.HTM. Accessed 6/29/08.

102
References
  • Bates SM, et al. Treatment of Deep Venous
    Thrombosis. NEJM, 7/15/2004.
  • AHA. Management of Deep Vein Thrombosis and
    Pulmonary Embolism. Circulation, 1996.
  • Venous Thromboembolism. Am Coll Physic, 2003.
  • Ramzi D, et al. DVT and Pulmonary Embolism Part
    1. Am Acad Fam Phys, 6/15/ 2004.
  • King V, Vaze AA, et al. D-Dimer Assay to Exclude
    Pulmonary Embolism in High-Risk Oncologic
    Population. Radiology 2008 247854-861.

103
References
  • James AH, Jamison, MG, Brancazio LR, Myers ER.
    Venous thromboembolism during pregnancy and the
    postpartum period incidence, risk factors, and
    mortality. Am J Obstet Gynecol.
    20061941311-1315.
  • Nijkeuter M, Geleijns J, De Roos A, Meinders AE,
    Huisman MV. Diagnosing pulmonary embolism in
    pregnancy rationalizing fetal radiation exposure
    in neurological procedures. J Thromb Haemost.
    200421857-1858.
  • Bentur Y. Ionizing and nonionizing radiation in
    pregnancy. In Koren G, ed. Maternal-Fetal
    Toxicology A Clinicians Guide, 3rd ed. New
    York, NY Marcel Dekker 2001603-651.
  • Winer-Muram HT, Boone JM, Brown HL, Jennings SG,
    Mabie WC, Lombardo GT. Pulmonary embolism in
    pregnant patients fetal radiation dose with
    helical CT. Radiology. 2002224487-492.

104
References
  • Ginsberg JS, Hirsch JS, Rainbow AJ, Coates G.
    Risks to the fetus of radiologic procedures used
    in the diagnosis of maternal venous
    thromboembolic disease. Thromb Haemost.
    198961189-196.
  • Russell JR, Stabin MG, Sparks RB, Watson E.
    Radiation absorbed dose to the embryo/fetus from
    radiopharmaceuticals. Health Phys.
    199773756-769.
  • Parker MS, Hui FK, Camacho MA, Chung JK, Broga
    BW, Sethi NN. Female breast radiation exposure
    during CT pulmonary angiography. Am J Roentgenol.
    20051851228.

105
References
  • Nickoloff EL, Alderson PO. Radiation exposures to
    patients from CT. Am J Roentgenol.
    2001177285-287.
  • Clemens S, Leeper KV. Newer modalities for
    detection of pulmonary emboli. Am J Med.
    2007120(10 suppl 2)S2-12.
  • Scarsbrook AF, Gleeson FV. Investigating
    suspected pulmonary embolism in pregnancy. BMJ.
    2007334418-419.
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