1 DVT/ PE Dr Faiza. A. Qari

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4 DVT Mortality/Morbidity: Death from DVT is attributed to massive pulmonary embolism Sex: The male-to-female ratio is 1.2:1 Age: older than 40 years.

5 History Many patients are asymptomatic. Edema, principally unilateral, is the most specific symptom. Leg pain occurs in 50%. Tenderness. Clinical signs and symptoms of pulmonary embolism. The pain and tenderness associated with DVT does not usually correlate with the size, location, or extent of the thrombus. Warmth or erythema of skin over the area of thrombosis

6 Physical Signs Physical: No single physical finding or combination of symptoms and signs is sufficiently accurate to establish the diagnosis of DVT. Tenderness, to the calf muscles or over the course of the deep veins in the thigh. Venous distension and prominence of the subcutaneous veins. Fever: usually low grade.

7 Physical signs Phlegmasia cerulea dolens –variable discoloration of the lower extremity., reddish purple from venous engorgement and obstruction.. Phlegmasia alba dolens –Painful white inflammation was originally used to describe massive ileofemoral venous thrombosis and associated arterial spasm. The affected extremity is often pale with poor or even absent distal pulses

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9 DD of DVT Achilles tendonitis Asymmetric peripheral edema secondary to CHF, liver disease, renal failure, or nephrotic syndrome Cellulitis, lymphangitis Ruptured Baker cyst Varicose veins

10 Causes of DVT –General Age Immobilization longer than 3 days Pregnancy and the postpartum period Major surgery in previous 4 weeks Long plane or car trips (>4 h) in previous 4 weeks –Medical Cancer Previous DVT Stroke Acute myocardial infarction (AMI) Congestive heart failure (CHF) Sepsis Nephrotic syndrome Ulcerative colitis

11 Causes Trauma –Multiple trauma –CNS/spinal cord injury –Burns –Lower extremity fractures –Vasculitis Systemic lupus erythematosus (SLE) and the lupus anticoagulant Behçet syndrome Homocystinuria –Drugs/medications IV drug abuse Oral contraceptives Estrogens Heparin-induced thrombocytopenia

12 Causes –Hematologic Polycythemia rubra vera Thrombocytosis Inherited disorders of coagulation/fibrinolysis Antithrombin III deficiency Protein C deficiency Protein S deficiency Factor V Leyden Dysfibrinogenemias and disorders of plasminogen activation

13 Lab Works Duplex ultrasonography. Contrast venography. 100 % diagnostic D dimer

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18 Pulmonary Embolism Massive PE is one of the most common causes of unexpected death. Although PE often is fatal, prompt diagnosis and treatment can reduce the mortality rate dramatically. Patients who survive an acute PE are at high risk for recurrent PE and for the development of pulmonary hypertension and chronic cor pulmonale.

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21 PE Race: is high in all racial groups. Sex: PE is common in all trimesters of pregnancy and the puerperium, and the incidence of PE is increased in women receiving oral contraceptive or hormone replacement therapy Age: Although the frequency of PE increases with age, Unfortunately, the diagnosis of PE is especially likely to be missed in older patients.

22 History PE is so common and so lethal that the diagnosis should be sought actively in every patient who presents with any chest symptoms that cannot be proven to have another cause. chest pain, chest wall tenderness,, syncope, hemoptysis, shortness of breath, painful respiration, new onset of wheezing, any new cardiac arrhythmia, or any other unexplained symptom referable to the thorax. The classic triad of signs and symptoms of PE (hemoptysis, dyspnea, chest pain).

23 History Many patients with PE are initially completely asymptomatic, and most of those who do have symptoms have an atypical presentation. Pleuritic or respirophasic chest pain is a particularly worrisome symptom.

24 Physical Clinical findings of pulmonary embolism –These findings are the primary manifestation in about 10% of patients with DVT. –In patients with angiographically proven pulmonary embolism, DVT is found in %.

25 Physical Examination Massive PE causes hypotension due to acute cor pulmonale,. New wheezing may be appreciated. The spontaneous onset of chest wall tenderness without a good history of trauma is always worrisome.

26 Physical signs Physical signs has been reported as follows: tachypnea (respiratory rate >16/min) –rales –accentuated second heart sound –tachycardia (heart rate >100/min) –fever (temperature >37.8° C) –diaphoresis –an S3 or S4 gallop –clinical signs and symptoms suggesting thrombophlebitis –lower extremity edema –cardiac murmur –cyanosis

27 Lab works ABG --- Decease PaO2, P Co2. ECG---- sinus tachychardia, S1,Q3,T3, RBBB, AF. Chest X ray – Normal, pleural effusion, consolidation, abrupt vessel cutoff. V/Q scan --- mismatch scan. Spiral CT scan Pulmonary arteriogram in case of low probability

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