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Thromboprophylaxis following S pinal C ord I njury

Thromboprophylaxis following S pinal C ord I njury. C P Vinod Duke of Cornwall Spinal Treatment Centre, Salisbury. Objectives. Venous Thrombo-Embolism (VTE) Spinal Cord Injury (SCI) Thromboprophylaxis following SCI. Venous Thrombo -Embolism. Blood Flow is essential for Life Arteries

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Thromboprophylaxis following S pinal C ord I njury

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  1. Thromboprophylaxis following Spinal Cord Injury C P Vinod Duke of Cornwall Spinal Treatment Centre, Salisbury

  2. Objectives • Venous Thrombo-Embolism (VTE) • Spinal Cord Injury (SCI) • Thromboprophylaxis following SCI

  3. Venous Thrombo-Embolism • Blood Flow is essential for Life • Arteries • Veins • Capillaries • Clotting of blood is also essential for life! • Thrombus – Blood Clot • Emboli – dislodged Clot

  4. Venous Thrombo-Embolism (VTE) • Pathophysiology • Virchow’s Triad

  5. Venous Thrombo-Embolism (VTE) • Pathophysiology • Virchow’s Triad • Haemodynamic Changes • Cardiac • Artificial Valves • Atrial Fibrillation • Atherosclerosis • Plaques • Immobility • Bed Rest • Paralysis

  6. Venous Thrombo-Embolism (VTE) • Pathophysiology • Virchow’s Triad • Haemodynamic Changes • Hypercoagulability • Dehydration • Infections • Malignanacy

  7. Venous Thrombo-Embolism (VTE) • Pathophysiology • Virchow’s Triad • Haemodynamic Changes • Hypercoagulability • Endothelial Injury • Trauma • Surgery

  8. Venous Thrombo-Embolism (VTE) • Pathophysiology • Virchow’s Triad • Haemodynamic Changes • Hypercoagulability • Endothelial Injury

  9. Venous Thrombo-Embolism (VTE) • Thrombosis/Emboli in Arteries • Stroke • Infarct • Ischemia • Thrombosis/Emboli in Veins (VTE) • Deep Vein Thrombosis • Pulmonary Embolism

  10. Spinal Cord Injury

  11. SCI - Epidemiology • Incidence - 11 to 40 per million • Prevalence – 10,000 in UK • 50% of SCI seen in 16 – 30 years age group • Median age 26 years • Traumatic SCI more common in <40 age group • Non-traumatic SCI more common in >40 age group

  12. Tetraplegia C8 and above C4 and above may be ventilator dependent Paraplegia T1 and below Below L3 may be able to walk Complete Incomplete Syndromes Central Cord Brown-Sequard Anterior Cord Cauda Equina Conus Medullaris SCI Classification

  13. SCI - Mortality/Morbidity • 1927 – Harvey Cushing described 80% mortality in WW 1 soldiers with SCI • Renal Failure & Pressure Sores • Today – In well organised centres 94% survive initial hospitalisation • Pneumonia, PE & Septicaemia

  14. Thromboprophylaxis in SCI • All patients have thromboprohylaxis for at least 12 weeks post spinal cord injury (Unless contraindicated) • We use LMWH

  15. Thromboprophylaxis in SCI • Clinical Practice Guidelines (CPG) for Spinal Cord Injury • Published by the Consortium for Spinal Cord Medicine

  16. Thromboprophylaxis in SCI • Second Edition Published in Sep 1999 • First edition 1997

  17. Thromboprophylaxis in SCI

  18. Thromboprophylaxis in SCI

  19. Thromboprophylaxis in SCI • Why is it so high following SCI? • Failure of Venous muscle pump • Transient hypercoagulable state • Alteration in Haemostasis • Reduced fibrinolytic activity • Increased factor VIII activity • Dehydration • Other injuries

  20. DVT relative to time Post SCI • 80% unprophylaxed patients develop DVT within the first 2weeks • Rossi et al 1980; Merli et al 1993 • 6% incidence at 8 week following stopping of prophylaxis • Green et al 1994

  21. Thromboprophylaxis in SCI • Incidence of PE not influenced by degree or level of SCI • Ragnarsson et al 1995 • Post Thrombotic Syndrome seen in over 60% • Chronic oedema, induration, Skin ulceration • Monreal et al 1993

  22. Mortality due to VTE in SCI • Autopsy in Acute SCI deaths -37% due PE • Tribe et al 1963 • Pulmonary Embolism • 3rd leading cause of death in Paraplegia • 2nd leading cause of death in Incomplete SCI • DeVivo and Stover 1995 • Risk of death due to PE in acute SCI • 210 times greater than healthy population • Decreases to 8.9 times after 5 years

  23. Thromboprophylaxis in SCI • VTE in SCI is a silent killer • Thromboprophylaxis (Mechanical or/and Pharmacological) if in doubt • Contact the nearest Spinal Injuries Centre

  24. Thromboprophylaxis in SCI Thank You

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