1. + Deep Vein Thrombosis Common, Preventable, and potentially Fatal

2. + Disclaimer Who am I W. Robert Leeper, MD PGY IV – General Surgery and Intensive Care Medicine Schulich School of Medicine and Dentistry University of Western Ontario Why am I giving this talk? 1) My research is in DVT and PE prevention 2) It’s the last talk of the day and they heard I was ‘energetic’ 3) I’m a resident so I’m very, very cheap

3. + Overview What IS a DVT/PE and WHY do I care? When should I SUSPECT a DVT/PE? How do I DIAGNOSE a DVT/PE? How do I PREVENT a DVT/PE? How do I TREAT a DVT/PE?

4. + What is a DVT/PE and why do I care? Etiology = Virchow’s Triad: Circulatory Stasis Intimal Injury Hypercoagulability Definition: A blood clot forming in a “deep” vein Usually lower extremity

5. + What is a DVT/PE and why do I care? Pulmonary Embolism: A blood clot that formed in a “deep” vein and then “embolized” back to the heart/lungs Commonly cited cause of the “late” trauma death

6. + What is a DVT/PE and why do I care?

7. + When should I SUSPECT a DVT/PE? First and foremost…….. BE VERY, VERY SUSPICIOUS!!!!

8. + When should I SUSPECT a DVT/PE? Incidence < 5% overall High Risk Injuries Head Injury (44%) Lower Limb # (52%) Pelvic # (37%) Spinal Cord Injury (15%) LHSC Data (2002 – 2007 ) High Risk Event Major OR < 4h (67%) SCD Contraindicated (74%) Prolonged Immobilization (93%) Missed doses of LMWH (100%) Humphrey, Parry, Girotti, Gray. Unpublished Data – Presented at TAC 2007

9. + When should I SUSPECT a DVT/PE? Incidence 5 – 10 % overall High Risk Injuries Spinal Cord Injury (LEVEL I) Lower Limb # (LEVEL II) Pelvic # (LEVEL II) Head Injury (LEVEL II) EAST Practice Guidelines High Risk Factors Older age (LEVEL II) Higher ISS (LEVEL II) Blood Transfusions (LEVEL II) Rogers et al. Management of Venous Thromboembolism in Trauma Patients. J Trauma. 53(1):142-164, July 2002.

10. + How do I DIAGNOSE a DVT/PE? Clinical Swollen, Painful, Erythematous Extremity SOB, pleuritic pain, tachypneia, hypoxia SUDDEN COLLAPSE Laboratory D-Dimer Blood gas, EKG, CXR Definitive US leg veins (9 to 5 test) VQ Scan or CT PE study (24/7 test)

11. + How do I DIAGNOSE a DVT/PE? Doppler US in ALL symptomatic patients Screening US in HIGH RISK patients LHSC Practice Doppler US in ALL symptomatic patients (LEVEL I) Screening US in HIGH RISK patients (LEVEL III) EAST Practice Guidelines

12. + How do I PREVENT a DVT/PE? Prevention Strategies Early Ambulation Prophylactic Anticoagulation Mechanical Compression Devices IVC Filters

13. + How do I PREVENT a DVT/PE? Early Ambulation No debate on this topic Level I evidence Multiple benefits beyond DVT/PE prevention Easier said than done ?

14. + How do I PREVENT a DVT/PE? Prophylactic Anticoagulation Typically LMWH Dalteparin 5000 units sc daily LHSC Practice LMWH for ALL eligible patients LMWH given throughout hospital stay

15. + How do I PREVENT a DVT/PE? EAST Guidelines LMWH for specific patients (LEVEL II) (lower extremity #, pelvic #, SCI…) LMWH for ISS > 9 (LEVEL III) LMWH specifically contraindicated with intracranial bleeding or epidural catheter (LEVEL III) Prophylactic Anticoagulation

16. + How do I PREVENT a DVT/PE? Mechanical Compression Devices (MCD) Preferred method if LMWH is contraindicated LHSC Practice MCD for ALL eligible patients EAST Guidelines MCD may not reduce rates of DVT/PE (LEVEL II) MCD may be indicated for SCI patients (LEVEL III)

17. + How do I PREVENT a DVT/PE? IVC Filters What are they? How do they work? When should we use them?

18. + How do I PREVENT/TREAT a DVT/PE? IVC Filters Traditional Indications (LEVEL 1) Known DVT + contraindication to anticoagulation Recurrent PE while on anticoagulation “Extended” Indications (LEVEL II) Free floating clot in iliac/IVC Following ‘massive’ PE “Prophylactic” Indications (LEVEL III) Any high risk injury type + contraindication to anticoagulation (SCI, Pelvic #, Extremity #, Severe closed head…)

19. + How do I PREVENT/TREAT a DVT/PE? IVC Filters – LHSC Experience 2000 – 2008 n = 27 filters Very selective utilization 85% retrieval rate Impressive retrieval rate Leeper, Gray, Kribs, Parry. Unpublished Data – Presented at ATS/TAC 2009

20. + How do I PREVENT/TREAT a DVT/PE? IVC Filters – LHSC Experience Leeper, Gray, Kribs, Parry. Unpublished Data – Presented at ATS/TAC 2009 Indication for Placement of IVCF in Trauma Patients 3 (11%) 10 (37%) 14 (52%) VTE Prophylaxis DVT (contraindication for anticoagulation) PE N = 27

21. + How do I PREVENT/TREAT a DVT/PE? IVC Filters – LHSC Experience Leeper, Gray, Kribs, Parry. Unpublished Data – Presented at ATS/TAC 2009 Figure 2 – Indication for Retrieval/Non Retrieval of IVCF 23 (85%) Successfully retrieved 2 (7%) Irretrievable due to trapped clot Died of Injuries Loss to Follow Up Rate = 0% N = 27

22. + How do I PREVENT/TREAT a DVT/PE? Treatment of Known DVT/PE Full Dose Anticoagulation IV Heparin infusion Fragmin at HIGH dose (200 u/kg) IVC Filter If anticoagulation contraindicated Thrombolytics vs Surgical Embolectomy Indicated for MASSIVE pulmonary embolism

23. + Summary – DVT/PE DVT and PE in Trauma Patients Maintain a HIGH INDEX of suspicion Maintain a LOW THRESHOLD to investigate Prevention >>> Cure

24. + Thank you Dr. W. Robert Leeper MD General Surgery and Critical Care Medicine - PGY IV Schulich School of Medicine and Dentistry The University of Western Ontario Rob.Leeper@gmail.com