Did You Know?

 Up to 2 million people in the United States suffer from DVT every year.

 Approximately 600,000 experience pulmonary embolism (PE).

 Venous Thromboembolism (VTE) is the term commonly used to describe both DVT and
PE.

For up to 200,000 of those with PE, the blood clot in the lung proves fatal – killing more people
than AIDS and breast cancer combined.
What Is Deep VeinThrombosis ?

3. DEFINITION Deep vein thrombosis is the formation of a blood clot in one of the deep veins
of the body, usually in the leg.

EPIDEMIOLOGY Venous ThromboEmbolism related deaths 3,00,000/anum 7% diagnosed

and treated 34% sudden pulmonary embolism 59% as undected

Virchows triad describes three factors that are thought to contribute to thrombosis

VIRCHOW TRIAD More than 100 years ago, Rudolf

Virchow described a triad of

factors of –
1. VENOUS STASIS prolonged bed rest (4 days or more) A cast on the leg Limb paralysis from
stroke spinal cord injury extended travel in a vehicle

2. HYPERCOAGULABILITY Surgery and trauma - 40% of all thrombo embolic disease Malignancy
increased estrogen Inherited disorders of coagulation -Deficiencies of protein-S, protein-C, anti-
thrombin III. Acquired disorders of coagulation- Nephrotic syndrome, Anti-phospholipid
antibodies

3. ENDOTHELIAL INJURY Trauma Surgery Invasive procedure Iatrogenic causes –central venous
catheters Subclavian Internal jugular lines These lines cause of upper extremity DVT.

 PATHOPHYSIOLOGY
 Vessel trauma stimulates the clotting cascade.
Platelets aggregate at the site particularly when venous stasis present
Platelets and fibrin form the initial clot RBC are trapped in the fibrin meshwork
 The thrombus propagates in the direction of the blood flow.

Inflammation is triggered, causing tenderness, swelling, and erythema.

 Pieces of thrombus may break loose and travel through circulation- emboli.

Fibroblasts eventually invade the thrombus, scarring vein wall and destroying valves.

Patency may be restored valve damage is permanent, affecting directional flow.

Thrombophlebitis - a thrombus accompanied by inflammation of the vein (phlebitis).

Phlebothrombosis - refers to a thrombus with minimal inflammation. Dislodgment and migration of
a thrombus are known as thromboembolism. Which is common in phlebothrombosis
Risk Factors for DVT
Medical conditions, such as:
Coronary Artery Disease
• Heart Failure
• Exacerbation of COPD or
other severe respiratory
disease
• Acute MI
• Trauma/Burns
• Sepsis
 • Inflammatory bowel disease
• Lupus
• Stroke
 Illness or injury that causes prolonged
immobility
 Age > 40
 Pregnancy, birth control pills and hormone
replacement therapy
 Cancer and its treatment
 Major surgery (ex: abdomen, pelvis, hip
facture, knee fracture, hip or knee
replacement)
 Surgery time > 30 minutes
 Obesity
 Indwelling vascular devices
 Previous DVT or PE
 Was Mrs. Smith at
Risk for DVT?
 47 years old
 She is recuperating from
surgery (abdominal
hysterectomy) one month ago.
 She was just in the emergency
dept. with flu-like symptoms;
has spent the last 3 days in
bed.
 She has a history of Lupus.
Yes! She certainly had several
risk factors.
The more risk factors a patient has, the greater the risk
for DVT

Could Mrs. Smith’s DVT

have been prevented?
– Identifying hospitalized patients
that are at high risk for
developing DVT
Implementing interventions to
prevent DVT
 Let’s review the important
interventions for the
prevention of DVT:
 Ambulation early and often
(simplest and most cost effective
means to reduce risk of DVT)
 Intermittent External
Compression Devices:
 Also called sequential compression
devices or SCDs
 They increase rate/velocity of
venous blood and reduce pooling in
the peripheral veins
 Compression should begin pre-
operatively and be continued until
the patient is fully ambulatory
 Anticoagulant Medication
Therapy
 PRESENTATION ANDPHYSICAL EXAMINATION Calf pain or tenderness, or
both Swelling with pitting oedema
Increased skin temperature and fever
Superficial venous dilatation
Cyanosis can occur with severe obstruction
Less frequent manifestations of venous thrombosis include Phlegmasia alba dolens,
Phlegmasia cerulea dolens, and Venous gangrene. These are clinical spectrum of the same

disorder.

 DIAGNOSTIC STUDIES
CLINICAL EXAMINATION Palpate distal pulses and evaluate capillary refill to assess
limb perfusion.
Move and palpate all joints to detect acute arthritis or other joint pathology.
 Neurologic evaluation may detect nerve root irritation; sensory, motor, and reflex deficits
should be noted
  Homans sign: pain in the posterior calf or knee with forced dorsiflexion of the foot.
 Moses sign Gentle squeezing of the lower part of the calf from side to side.

Neuhofs sign Thickening and deep tenderness elicited while palpating deep in calf muscles.
Lintons sign After applying torniquet at saphenofemoral junction patient made to walk , then
limb is elevated in supine posation prominent superficial veins will be observed.

Clinical examination alone is able to confirm only 20-30% of cases of DVT

 Clinical diagnosis of DVT is unreliable because classic symptoms (pain, swelling,

tenderness, and warmth) may not be present.

 Therefore it is important for ALL healthcare professionals to collaborate in the

identification of high risk patients and implement prophylaxis.

 Blood Tests The D-dimer

Imaging Studies

 Venography – ex-gold standard

 Duplex Ultrasound
 What’s happening at
American Mission
Hospital?
 We are focusing on DVT prophylaxis
for all in-patient admissions.
 Requires the physician to place the
order for the appropriate DVT
prophylaxis
 EMERGENCY DEPARTMANTCARE
The primary objectives of the treatment of DVT are to
 prevent pulmonary embolism
 reduce morbidity, and
 prevent or minimize the risk of developing the postphlebitic syndrome.

 GENERAL THERAPEUTICMEASURES
 Bed rest .
 Encourage the patient to perform gentle foot & leg exercises every hour.
 Increase fluid intake upto 2 l/day unless contraindicated.
 Avoid deep palpation .
 SPECIFIC TREATMENT :
 Anticoagulation
 Thrombolytic therapy for DVT
 Surgery for DVT
 Filters for DVT
 Compression stockings
 Initial treatment of DVT is with low- molecular-weight heparin or
unfractionated heparin for at least 5 days, followed by warfarin (target INR,
2.0–3.0) for at least 3 months.Heparin prevents extension of the thrombus
 Remember
 Major risk factors for DVT
include:heart failure, severe
respiratory disease and sepsis.
 All patients’ DVT risk factors
are identified on admission
 If an acutely ill hospitalized
patient has a major risk factor
for DVT or is confined to bed
and has one or more additional
risk factors, then prophylaxis is
recommended