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PE & DVT treatment

PE & DVT treatment. Fat and Marrow Sequelae from any marrow/adipose injury fat and cells are released into bloodstream CPR, long bone fractures, setting of soft tissue or burns. Classification of Emboli. Air Clinical effect: >100 cc air Air coalesce  frothy masses

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PE & DVT treatment

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  1. PE & DVT treatment

  2. Fat and Marrow • Sequelae from any marrow/adipose injury • fat and cells are released into bloodstream • CPR, long bone fractures, setting of soft tissue or burns. Classification of Emboli

  3. Air • Clinical effect: >100 cc air • Air coalesce  frothy masses • Introduced via surgical procedures, e.g. Laparoscopic, obstetric, bypass • Decompression sickness: deep sea divers, underwater workers.

  4. Amniotic Fluid • Amniotic fluid/fetal tissue in maternal circulation • Originates at tears of placental membranes or rupture of uterine veins. • 5th most common cause of maternal mortality

  5. Goals: • prevent clot propagation • Prevent pulmonary hypertension • recurrence of clot • Tx: anticoagulant therapy + warfarin 6-12 weeks • Non-pharm measures: leg elevation, heat application, compression stockings • Can treat with outpatient based (except PE) Tx of DVT

  6. 1. oxygen 100% • 2. morphine IV if pain/distressed • 3. Massive PE: thrombolysis/surgery • 4. IV  heparin as guided by APTT • 5. Systolic BP • >90mmHg: warfarin  confirm Dx PE • <90mmHg:colloid infusion  noradrenaline  consider thrombolysis (if not step 3) Tx of PE

  7. Delay in Dx: treat presumptively • Contraindications: intracranial bleeding, severe active bleeding, recent brain, eye, or spinal cord surgery, and malignant hypertension • Heparin • Activates antithrombin to II, VII, IX, X, XI, XII • Warfarin • Inhibits reductase to activate Vit K – cofactor of cascade Anticoagulant Therapy

  8. Pros • Cheaper • Use for patients with renal insufficiency/failure • Indicated for submassive/massive PE • ADR: • Thrombocytopenia (transient 10-20%), major bleeding (2%) • Risk: >65yrs, recent surgery, liver disease Unfractionated Heparin

  9. LMWH (Fractionated Heparin) • more predictable anticoagulant effects • does not require blood monitoring • outpatient therapy • Longer half-life • Subcutaneous admin. • ADRs of UF less likely Low Molecular Weight Heparin

  10. Therapy starts when acute anticoagulation is achieved • starting Tx at 5 mg per day • Titrating the dosage every 3-7 days to achieve an INR between 2.0 and 3.0 • E.g. Day 3 INR <3 10 mg/day or INR <2.0-2.9 2.5 mg/day Warfarin

  11. Not used for DVTs • Used when anticoagulant therapy fails • Indicated for massive PE • Include: streptokinase, tPA via IV Thrombolytic Therapy

  12. A transvenous catheter embolectomy or open surgical embolectomy • Indications: • thrombolytic therapy fails • Contraindicated for thrombolytic therapy • Massive PE + refractory hypotension • Vena cava filters for recurrent PEs • Combined with anticoagulation therapy Surgical Therapy

  13. Prevent further thrombosis • Heparin + warfarin for ≥5 days. • Stop heparin at INR>2. • Warfarin therapy depends on underlying cause, vary from 3-6 months or indefinite. • Warfarin is contraindicated in pregnant women, use LWMH instead. Management

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