DVT

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DVT PE

• Cindy Fehr
• Malaspina University-College
• BSN Nursing Program
• Nursing 335 Fall 2005

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FACTS

• Orthopedic injuries place at ? risk
• DVT formation of thrombus in deep vein,
  typically in lower extremity
• PE thrombus that travels into the pulmonary
  circulation

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Pathophysiology of DVT

• Prevention is key
• Identify those at high risk
• Virchows triad ? changes in blood coagulability,
  changes in vessel wall, changes in blood flow
• Prophylactic tx with oral anticoagulant or LMW
  heparin
• Intermittent pneumatic compression devices (calf
  compressors) or elastic stockings (TEDS)
• Early ambulation
• Early identification treatment of DVTs
• treat with vena cava filters

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Coagulation Pathways

• Extrinsic Pathway - activated when tissue trauma
  occurs
• Intrinsic Pathway - activated under conditions
  such as stress, anxiety, or fear, and in the
  absence of external tissue injury
• stage one cascade - either the intrinsic or
  extrinsic pathway ends with the formation of
  prothrombin-converting factor
• stage two prothrombin-converting factor begins
  series of chemical interactions ? slowly converts
  prothrombin to thrombin.
• Stage three fibrinogen interacts with thrombin to
  form fibrin.
• erythrocytes, phagocytes, and microorganisms,
  also collect at the site to complete thrombosis
  development

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predisposing factors of DVT

• advanced age
• trauma
• spinal cord injury
• immobilization
• myocardial infarction
• heart failure
• stroke
• previous thromboembolic disease
• thrombotic abnormalities
• obesity
• pregnancy
• constricted clothing
• homocystinuria
• systemic lupus erythematosus
• inflammatory bowel disease
• central venous catheter use
• oral estrogen use

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Pulmonary Embolism

• About 10 of PEs result in immediate death
• a futher 20 kill later if they're untreated
• Once treated, the mortality rate drops to 3.

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Source Nucleus Medical Art Online
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Venous thromboembolism (PE)

• a serious and commonproblem that can and should
  be prevented
• A serious problem
• 80 of PE occur without signs
• 2/3 of deaths occur within 30 minutes
• A common problem
• One in 100 hospitalized patients dies of PE
• Can should be prevented

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These pulmonary emboli removed at autopsy look
like casts of the deep veins of the leg where
they originated. Source www.DVT.ORG
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What increases the chances of having a pulmonary
embolism?

• Older adults, especially those who are bedridden
• People who have or have had cancer
• Anyone who has recently undergone surgery,
  especially in the abdomen
• Family history of pulmonary embolism
• Obesity
• Recent fracture of the pelvis or legs
• Pregnant women and women who have recently given
  birth
• Oral contraceptive use

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The main symptoms of a Pulmonary Embolus are

• Chest pain
• Typically under the breastbone or to one side
• Typically a sharp stabbing pain
• Typically made worse when breathing in
• Shortness of breath
• A mild temperature (typically 38C), with
  sweating
• Rapid pulse
• A dry cough, sometimes with blood (usually small
  amounts, sometimes more)
• A feeling of anxiety

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There are three main tests which can be
performed

• D-dimer represents fibrin split products that
  are released into the blood stream when there are
  clots in the blood stream
• Chest X-ray helpful to eliminate other
  possibilities, but 25 of PEs don't show up on an
  ordinary x-ray
• Ventilation Perfusion scan (V/Q scan) good
  initial screening test, but notoriously difficult
  to analyse
• CT scan the definitive diagnostic tool

Source American Family Physician Journal Sept.
2001
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Treatment

• to thin the blood using anti-coagulants.
• initial injection (bolus) of heparin, followed by
  a heparin infusion for several days
• although heparin provides immediate protection,
  it has an extremely low half-life, so it only
  protects you while you're being infused with it
• a longer-lasting anti-coagulant is used for
  ongoing protection. (warfarin)
• on heparin until blood tests (INR test) confirms
  that warfarin is keeping your blood two or three
  times thinner than usual

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Treatment cont.

• Less common treatments include
• These options are used when anti-coagulation is
  proving ineffective or where the clot is so
  severe that it is too dangerous to wait for the
  clots to dissolve in the thinned blood
• clot-filters
• clot-busting drugs
• surgery

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Prevention

• To help prevent development of blood clots in the
  venous system
• Pressure stockings
• early ambulation
• low dose heparin
• use of sequential compression