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DEEP VEIN THROMBOSIS (DVT)

Posted by SAMUEL ISABIRYE on February 5, 2013 at 4:50 PM

Clot formation within the deep venous system

usually of the calf, thigh or pelvic veins. The clot

can cause a local problem at site of formation or

dislodge leading to thromboembolism in various

parts of the body, particularly the lungs.

 

Causes

 

z

Venous stasis (immobilization, prolonged bed

rest, surgery, limb paralysis)

 

z

Heart failure, myocardial infarction

 

z

Blunt trauma

 

z

Venous injury including cannulation

 

z

Increased coagulability states such as those

associated with some medicines – oral

contraceptive pills, chemotherapy

 

z

Malignant disease of pancreas, lung, stomach,

prostate

 

z

Pregnancy and postpartum

 

z

Polycythaemia

 

z

Anaesthesia – general

 

z

Stroke

 

z

Long distance air travel

 

Clinical features

 

z

50% of cases may be clinically silent

 

z

Painful swelling of the calf, thigh and groin with a

positive Homans’ sign (unreliable for diagnosis)

 

z

Dislodgment of the thrombus may lead to a

greater risk of pulmonary embolism characterized

by fever, pleuritic chest pain, haemoptysis,

dyspnoea.

 

Differential diagnosis

 

z

Cellulitis

z

Myositis

z

Contusion

 

UCG 2010

193

 

 

 

9. Cardiovascular diseases

z

Sarcoma of the underlying bone

z

Phlebitis

z

Karposis sarcoma of the leg

 

Investigations

 

¾

Blood: haemogram, clotting/bleeding time,

fibrinogen degredation products. Prothrombin time

(PT) and International Normalised Ratio (INR).

 

¾

In case of pulmonary embolism: ECG, chest X-ray,

 

echo cardiogram.

¾

Venogram

¾

Ultrasound (at specialised centres)

 

Management

HC4

f

Fibrinolysis at specialised centers

f

Unfractionated heparin given as: IV bolus

5000 IU stat then 250 IU units per kg

subcutaneuosly12 hourly for 5 days adjust dose

according to APTT maintain INR between 2 - 3.

 

f

Low molecular weight heparin (enoxaparin)

 

1mg/kg daily (LMWH) for 5 days can be used as

an alternative

 

f

plus warfarin

 

5mg single dose given in the evening,

commencing on day 3.

-

maintenance dose: 2.5-7.5mg single dose

daily, adjusted according to the INR 2 -3.

f

Check for bleeding and monitor Prothrombin

Time (PT) and INR.

 

f

Starting therapy with warfarin alone

increases the risk of thrombus progression

and embolisation.

 

Antidotes for anticoagulants HC4

 

For heparin:

 

f

protamine sulphate: 50mg slow IV (over 10

minutes) will neutralise the action of 5,000 IU of

heparin when given within 15 minutes of heparin

 

UCG 2010 194

 

 

 

9. Cardiovascular diseases

-

1mg protamine neutralises approx 80-100 IU

heparin (max dose: 50mg)

 

-

if protamine is given longer than 15 minutes

after heparin, less is required as heparin

is rapidly excreted

 

For warfarin:

 

f

phytomenadione (vitamin K) usually 2-5mg

SC, or oral

-

in severe haemorrhage transfusion with fresh

frozen plasma (15mls/kg) or fresh whole

blood.

-

dose depends on INR and degree of

haemorrhage; large doses may reduce

response to resumed warfarin therapy for a

week or more

 

Note:

 

.

Check for bleeding and monitor INR and PT

 

Prevention:

 

.

Early ambulation

 

.

Prophylaxis with Heparin in any acutely ill

medical patient and prolonged admission.

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1 Comment

Reply SAMUEL ISABIRYE
3:52 AM on February 19, 2013 
this research is summerised