PULMONARY EMBOLISM/DVT


  • Chest pain
  • Sudden onset SOB (Dyspnea)
  • Fever ( 100.0 F)
  • Sinus Tachycardia
  • Tachypnia
  • Hemoptysis

CXR

+
D-Dimer
(will always be
in pt. w/ renal failure OR post-surgery)

Normal

Abnormal


V/Q Scan
(if still suspicious OR in pt. w/ renal insufficiency)


CTA

(V/Q scan for pt. w/ renal insufficiency)

(+)
High Probability
(-)
Low Probability
(-) (+)
Unstable
(sBP <90)
Stable
(sBP > 90)
 Lower ext. doppler
tPA
- Alteplase 100 mg IV over 2hr, start heparin at the end of infusion
OR
- Reteplase 10 Units IV initially, followed by second dose of 10 Units 30min later
 
Regular Tx Low Probability High Probability Start Tx
Nothing
Lower ext. doppler
 

(-)
But HIGH probability

 (+)

CT Angio

Start Tx

Pulmonary Embolism Rule-Out Criteria
Age <50 y
Pulse oximetry >94% (breathing room air)
Heart rate <100 beats/min
No prior venous thromboembolism
No recent surgery or trauma (requiring hospitalization, intubation, or epidural anesthesia within prior 4 wk)
No hemoptysis
No estrogen use
No unilateral leg swelling

Diagnosing DVT

  • D-dimer <500 and low probability Well’s Score = DVT unlikely
  • Moderate or high probability Wells score = non-invasive testing (Venous Duplex US)
    • Venous compression ultrasounds have 94% positive predictive value
    • If negative and clinical suspicion is high, repeat US at 5-7 days


Source: Tintinalli ED 7th ed

Screening for Malignancy

  • Cancer risk = 1.3x expected
  • Complete H&P (with rectal and pelvic exams)
  • CBC, LFTs, CXR, stool guaiac
  • Aggressive cancer work-up not necessary or cost-effective
    • – CA usually made its presence known prior to VTE
    • – Lung, Pancreas, Colon, Kidney, Prostate

 

Screening for Thrombophilia

  • Initial thrombosis prior to age 50
  • Family history of VTE
  • Recurrent venous thrombosis
  • Unusual vascular beds
  • Warfarin induced skin necrosis
  • Testing
    • Protein C
    • Protein S
    • Fibrinogen
    • Anti-thrombin III
    • Factor V Leiden
    • Lupus anticoagulant
    • Anticardiolipin antibody
    • Prothrombin gene mutation

 

Risk Factors for Venous Thromboembolism (VTE)

Factor Comment
Age Risk becomes significant at 50 y and increases with each year of life until age 80 y.
Obesity Risk starts at BMI >35 kg/m2 and increases with increasing BMI.
 
Pregnancy Risk increases with trimester (but overall risk remains low throughout pregnancy).
Solid cancers Risk greatest with adenocarcinomas and metastatic disease. A history of remote, inactive cancer probably does not increase risk.
Hematologic cancers Acute leukemias confer the greatest risk.
Inherited thrombophilia Factor V Leiden and familial protein C deficiency have the strongest risk.
Recent surgery or major trauma Risk continues at least 4 wk postoperatively or after trauma intensive care.
Immobility Acute limb immobility confers the highest risk.
Bed rest Becomes a risk factor at approximately 72 h.
Indwelling catheters Cause approximately one half of arm deep venous thromboses.
Long-distance travel Published data are controversial.
Smoking Not a risk factor itself, but may increase risk of other factors such as oral contraceptives.
Congestive heart failure Related primarily to severity of systolic dysfunction.
Stroke Risk greatest in first month after deficit.
Estrogen All contraceptives containing estrogen increase risk of VTE.
Noninfectious inflammatory conditions Examples are inflammatory bowel disease, lupus, nephrotic syndrome. Risk of VTE increases roughly in proportion to severity of underlying disease.
 

Factors Known to Alter the D-Dimer Level

Potential False Positive Levels Potential False Negative Levels
Age >70 y Warfarin treatment
Pregnancy Symptoms lasting over 5 d
Active malignancy or metastasis Presence of small clots
Surgical procedure in previous week Isolated small pulmonary infarction
Liver disease Isolated calf vein thrombosis
Rheumatoid arthritis  
Infections  
Trauma  
 

Hospital Admission Criteria:

An extensive iliofemoral deep venous thrombosis with circulatory compromise
An increased risk of bleeding (coagulopathy, active peptic ulcer disease, liver disease) that requires close monitoring of therapy
A limited cardiorespiratory reserve
A risk of poor compliance with home therapy regimen or inadequate support (i.e., community, social, or medical), or concern with ability to arrange follow-up
A contraindication to use of low-molecular-weight heparin, which would necessitate IV heparin therapy
Coexistent pulmonary embolism
A high suspicion of heparin-induced thrombocytopenia without or with thrombosis
Renal insufficiency requiring monitoring of anti–Factor Xa level, or use of unfractionated heparin
 

Treatment

Treatment
Stable
(sBP >90)
Unstable
(sBP < 90)
  1. O2
  2. Aggressive IV fluids (500 ml or 1L bolus)
  3. Lovenox 1 mg/kg/dose SQ q 12 h x 5 days. (Pregnant: for at least 6 wks postpartum, Underlying malignancy: for 3-6 months)
    OR
    Heparin 80 units/kg IV bolus initially, followed by 18 units/kg/hr, adjust dose according to PTT
    OR
    Arixtra:
    pt weight < 50 kg
    : 5mg SQ qd;
    pt. weight 50-100 kg:
    7.5 mg SQ qd;
    pt weigh > 100 kg:
    10 mg SQ qd.
    PLUS
     
  4. Warfarin 5-10 mg PO qd for 2-3 d, then 2-5 mg PO qd. (INR = 2-3), Contraindicated in pregnancy. [Duration]
  5. IVC filter (indications)
  6. Thrombolysis - ONLY when pt hemodynamically unstable
  7. Work-up for cause of PE/DVT
  8. Compression stockings should be started within one month and maintained for at least one year to prevent post-thrombotic syndrome.
  9. Anticoagulation should be maintained for
    • 3-6 months for VTE due to transient factors 
    • >12 months for recurrent VTE
rt-PA
- Alteplase 100 mg IV over 2hr, start heparin at the end of infusion
OR
- Reteplase 10 Units IV initially, followed by second dose of 10 Units 30min later
Antithrombotic Therapy for Deep Venous Thrombosis (DVT) and Pulmonary Embolism (PE)
  Dosage Comments
Upper or lower extremity DVT antithrombotic therapy  Outpatient therapy generally preferred 
Unfractionated heparin 80 units/kg bolus, then 18 units/kg/h infusion Recommended if outpatient therapy not appropriate, or in cases of severe renal failure
LMWHs   Outpatient treatment with LMWH preferred
  Dalteparin 100 IU/kg SC every 12 h or 200 IU/kg SC every day  
  Enoxaparin 1 mg/kg SC every 12 h or 1.5 mg/kg SC every day  
  Tinzaparin 175 IU/kg SC every day  
Factor Xa inhibitors    
  Fondaparinux <50 kg, 5 mg SC every day; 50–100 kg, 7.5 mgSC every day; >100 kg, 10 mg SC every day Do not use in renal failure
PE antithrombotic therapy  Inpatient therapyy 
Unfractionated heparin 80 units/kg bolus, then 18 units/kg/h infusion A standard treatment for PE; recommended over LMWH for submassive or massive PE, or in situations in which SC absorption is questioned
LMWHs See above for agents and dosages  
Factor Xa inhibitors See above for agents and dosages  
Thrombolytic therapy Tissue plasminogen activator or alteplase (Activase), 100 mg infused over 2 h For PE

Admit Orders: Pulmonary Embolus

1. Admit to:

2. Diagnosis: Pulmonary embolism

3. Condition:

4. Vital Signs: q1-4h. Call physician if BP >160/90, <90/60; P >120, <50; R >30, <10; T >38.5°C; O2 sat < 90%

5. Activity: Bedrest with bedside commode

6. Nursing: Pulse oximeter, guaiac stools, O2 at 2 L by NC. No intramuscular injections.

7. Diet: Regular

8. IV Fluids: D5W at TKO.

9. Special Medications:

Anticoagulation:

-Heparin IV bolus 5000-10, 000 units (100 U/kg) IVP, then 1000-1500 units/h IV infusion (20 U/kg/h) [25, 000 units in 500 mL D5W (50 U/mL)]. Check PTT 6 hours after bolus; adjust q6h until PTT 1.5-2 times control (60-80 sec). Overlap heparin and Coumadin for at least 4 days and discontinue heparin when INR has been 2.0-3.0 for two consecutive days
OR

-Enoxaparin (Lovenox) 1 mg/kg SQ q12h for 5 days for uncomplicated pulmonary embolism. Overlap enoxaparin and Coumadin for at least 4 days and discontinue heparin when INR has been 2.0-3.0 for two days

-Warfarin (Coumadin) 5-10 mg PO qd for 2-3 d, then 2-5 mg PO qd. Maintain INR of 2.0-3.0. Coumadin is initiated on second day if the PTT is 1.5-2.0 times control. Check INR qd [tab 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10 mg].
 

Thrombolytics (indicated for hemodynamic compromise):

Baseline Labs: CBC, INR/PTT, fibrinogen q6h.
 

Alteplase (recombinant tissue plasminogen activator, Activase): 100 mg IV infusion over 2 hours, followed by heparin infusion at 15 U/kg/h to maintain PTT 1.5-2.5 x control 
OR

Streptokinase (Streptase): Pretreat with methylprednisolone 250 mg IV push and diphenhydramine (Benadryl) 50 mg IV push. Then give streptokinase, 250, 000 units IV over 30 min, then 100, 000 units/h for 24-72 hours. Initiate heparin infusion at 10 U/kg/hour; maintain PTT 1.5-2.5 x control.
 

10. Symptomatic Medications:

--Docusate sodium (Colace) 100 mg PO qhs.

-Famotidine (Pepcid) 20 mg IV/PO q12h
OR

-Lansoprazole (Prevacid) 30 mg qd.
 

11. Extras: CXR PA and LAT, ECG; spiral chest CT scan; duplex ultrasonography of lower extremities.

12. Labs: CBC, CMP, ABG, troponin, d-dimer. Protein C, protein S, antithrombin III, anticardiolipin antibody. UA . PTT q4-6h. INR qd.

 

Admit Orders: DVT

1. Admit to:

2. Diagnosis: Deep vein thrombosis

3. Condition:

4. Vital Signs: q shift. Call physician if BP systolic >160, <90 diastolic, >90, <60; P >120, <50; R>25, <10; T >38.5°C.

5. Activity: Bed rest with legs elevated; bedside commode.

6. Nursing: Guaiac stools, warm packs to leg prn; measure calf and thigh circumference qd; no intramuscular injections.

7. Diet: Regular

8. IV Fluids: D5W at TKO

9. Special Medications:

Anticoagulation:

--Heparin (unfractionated) 80 U/kg IVP, then 18 U/kg/hr IV infusion. Check PTT 6 hours after initial bolus; adjust q6h until PTT 1.5-2.0 times control (50-80 sec). Overlap heparin and Coumadin for at least 4 days and discontinue heparin when INR has been 2.0-3.0 for two consecutive days 
OR

-Enoxaparin (Lovenox) for outpatients: 1 mg/kg SQ q12h for DVT without pulmonary embolism. Overlap enoxaparin and warfarin for 4-5 days until INR is 2-3.

-Enoxaparin (Lovenox) for inpatients: 1 mg/kg SQ q12h or 1.5 mg/kg SQ q24h for DVT with or without pulmonary embolism. Overlap enoxaparin and warfarin (Coumadin) for at least 4 days and discontinue heparin when INR has been 2.0-3.0 for two consecutive days.

-Warfarin (Coumadin) 5-10 mg PO qd x 2-3 d; maintain INR 2.0-3.0. Coumadin is initiated on the first or second day if the PTT is 1.5-2.0 times control [tab 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10 mg].

10. Symptomatic Medications:

-Hydrocodone/acetaminophen (Vicodin), 1-2 tab q4-6h PO prn pain.

-Docusate sodium (Colace) 100 mg PO qhs.

-Famotidine (Pepcid) 20 mg IV/PO q12h
OR

-Lansoprazole (Prevacid) 30 mg qd.

-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
 

11. Extras: CXR PA and LAT, ECG; Doppler scan of legs. Chest CT scan.

12. Labs: CBC, INR/PTT, CMP, d-dimer. Protein C, protein S, antithrombin III, anticardiolipin antibody. UA with dipstick for blood. PTT 6h after bolus and q4-6h until PTT 1.5-2.0 x control then qd.