What thrombophilias may be screened for if indicated in a patient with a VTE
Factor V Leiden, prothrombin G20210A mutation, protein C and S deficiency, antithrombin III, anti-phospholipid antibodies, hyperhomo-cysteinemia.
What drugs should be avoided after a VTE?
Exogenous estrogen therapy
When is an IVC filter indicated?
Patients with contraindication to anticoagulation, a serious complication of anticoagulation, or recurrent thromboembolism despite adequate anticoag.
When is thrombolysis indicated with a VTE
- When a patient has a massive PE and associated hemodynamic instability.
- Alteplase-100mg IV infusion over 2hrs.
- Streptokinase-250,000 IU loading dose, followed by 100,000 IU per hour for 24hrs.
Unfractionated Heparin IV, what is the goal aPTT
1.5 to 2.5 times the control.
What is the first priority in treating the patient with VTE?
- Heparin! Typically for 5 days until stable therapeutic INR is established with Warfarin-Enoxaparin 1mg/kg SC BID or Tinzaparin 175 anti-Xa IU/kg SC QD or
- Fondaparinux SC QD
- <50 kg- 5mg
- 50-100 kg 7.5mg
- >100 kg- 10mg
- Oral Warfarin is started simultaneously
Wells clinical decision rule for PE
- Risk factor #of points
- Clinical s&s of DVT (3)
- Alternative dx less likely than PE (3)
- HR greater than 100 BPM (3)
- Immobilization or surgery in past 4 wks (1.5)
- Previous DVT or PE (1.5)
- Hemoptysis (1.5)
- Malginancy (1)
- Low <2
- Moderate: 2-6
- High: >6
Key elements of H and P for leg pain and swelling
- Immobilization (>3d in past 4wk)
- Venous dilatation
- Recent surgery
- Temperature difference
- Calf pain
- Homan sign
- Local tenderness
Wells clinical decision rule for DVT
- Risk Factor (1pt for each)
- Active cancer (tx ongoing within previous 6 months or palliative)
- Paralysis, paresis, or recent plaster immobilization of lower extremities
- Recently bedridden for >3days or major surgery w/in 4 weeks.
- Localized tenderness along distribution of deep venous system
- Entire leg swelling
- Calf swelling by >3cm when compared with the asymptomatic leg (measured 10cm below tibial tuberosity)
- Pitting edema(greater in symptomatic leg)
- Collateral superficial veins (nonvaricose)
- Alternative diagnosis as likely or greater than that of DVT (-2 points)
- Low <0
- Moderate 1-2
- High >2
Symptoms and Signs in acute PE
- Symptom: dyspnea(73%), pleuritic chest pain(66%), cough(37%), hemoptysis(13%)
- Sign: tachypnea(70%), Rales (51%), tachycardia(30%), 4th heart sound(24%), accentuated pulmonic component of 2nd heart sound (23%), circulatory collapse(8%).