Thromboembolic Disease- Deep Vein Thrombosis (DVT)

Definition/Etiology:

Thromboembolic disease is the formation of blood clot which blocks a blood vessel. Clots can form due to hereditary or acquired factors. Patients often have multiple causes.

• Veins are a low-pressure system, and any blood that pools or stagnates can clot.
• Long flights or sedentary periods (post-op bedrest) can cause blood to pool in the legs.
• Dehydration, leukemia, and sickle cell disease increase viscosity (thickens the blood) and makes clotting more likely.
• Genetic disorders can make certain people clot more than others: Factor V Leiden, Protein C deficiency, Protein S deficiency, Antiphospholipid Syndrome, Anticardiolipin, etc.
• Hormone supplements such as testosterone and estrogen can increase clotting and should be avoided in smokers and in patients with genetic predisposition.
• Varicose veins can increase stagnation of blood.
• Injury to vessels (IVs, central lines) can precipitate clot.
• Cancers of all types can increase risk of clot formation.

Pathophysiology:

Hereditary vs. acquired

Virchow Triad:

• Alteration in blood flow (stasis, bedrest, flight)
• Vascular injury (central line)
• Inherited or acquired hypercoagulable state (cancer, genetic disorder, dehydration)

Clinical Presentation:

DVT:

• Pain
• Isolated edema in limb
• Erythema

PE:

• Pleuritic chest pain
• Impending doom
• Dyspnea

CVA (FAST mnemonic):

• Face (unequal smile)
• Arm drift
• Speech slurred
• Time (of onset)

Collaborative Management:

Testing:

• PT/INR, PTT, D-dimer
• Ultrasound
• CT angiogram
• VQ scan
• Echocardiogram with bubble study

Interventions:

• Heparin gtt or low molecular weight heparin
• Initiate oral anticoagulation
• IVC filter can be considered
• Interventional radiology for thrombectomy (clot snare), drip thrombolytic (clot buster)
• Compression stockings

Management:

• 3-6 months of anticoagulation vs lifetime

Evaluation | Patient Monitoring | Education:

• Teach patient signs and symptoms of gastrointestinal bleeding.
• Monitor labs (CBC for all, INR if on Warfarin, PTT if on Heparin).
• Teach patient about dietary considerations if on Warfarin (vitamin K foods), and to be aware that certain antibiotics can increase INR if also on Warfarin.

Linchpins: (Key Points)

• Blood clots can cause death if they travel and cause pulmonary embolism or stroke.
• Virchow Triad (spokes):
  • Stasis
  • Vascular injury
  • Hypercoagulable state (Inherited or acquired)