Venous%20thromboembolism%20-%20management Signs and Symptoms
Definition
Venous Thromboembolism (VTE)
- Most commonly manifested as pulmonary embolism (PE) and deep venous thrombosis (DVT), and is associated with significant morbidity and mortality
- ⅓ of patients present with symptoms of DVT and ⅔ with PE
- Also manifests as superficial vein thrombosis (SVT), a less severe form of DVT
- One of the most common life-threatening cardiovascular diseases in the US and with increasing incidence and mortality rates in Asia
- All patients admitted for major trauma, surgery or acute medical illness should be assessed for risk of VTE and bleeding before starting prophylaxis of VTE
- Studies show that appropriate VTE prophylaxis should be given to surgical patients in Asia who are at risk for VTE
Deep Vein Thrombosis (DVT)
- Frequent manifestation of VTE in which there is a blood clot blocking a deep vein
- Patients are generally asymptomatic with a calf DVT but becomes symptomatic with proximal extension of the DVT and venous outflow obstruction
Pulmonary Embolism (PE)
- Blockage of the blood vessels in the lungs usually due to blood clots from the veins, especially the veins in the legs and pelvis
Pathogenesis
- Virchow’s triad theorizes 3 factors contributing to the development of VTE: Hypercoagulability, endothelial damage, and stasis
- Hypercoagulability has been associated with factor V Leiden mutation and prothrombin gene mutation
- Cancer also produces a hypercoagulable state due to the procoagulant activity produced by malignant cells and also secondary to effects of chemotherapeutic agents
- Major contributing risk factors include history of trauma, surgical procedures, spinal cord injury, long bone fractures, and previous VTE
Signs and Symptoms
Deep Vein Thrombosis (DVT)
- Localized tenderness along the distribution of the deep venous system
- Unilateral or entire leg is swollen
- Calf swelling >3 cm compared to asymptomatic leg (measured 10 cm below tibial tuberosity)
- Pitting edema is greater in the symptomatic leg
- Collateral superficial veins (non-varicose)
- Erythema
- Warmth
- Superficial thrombophlebitis with a palpable cord over a superficial vein
- Phlegmasia cerulea dolens (blue leg) - deoxygenated hemoglobin in the stagnant veins causes a cyanotic hue in the leg
- Phlegmasia alba dolens (pale leg) - pallor in the edematous legs because the interstitial tissue pressure has exceeded capillary perfusion pressure
Pulmonary Embolism (PE)
- Suspicion of PE is usually raised by the clinical symptoms
- Clinical findings are nonspecific and should not be the only criteria to diagnose PE
- Dyspnea, pleuritic chest pain, syncope and tachypnea [respiratory rate (RR) ≥20/minute] occur in most cases of PE
- Dyspnea is the most frequent symptom, while tachypnea is its most frequent sign
- Other signs and symptoms that may be present: Tachycardia [heart rate (HR) >100/minute], cough and hemoptysis, fever, diaphoresis, nonpleuritic chest pain, apprehension, rales, increasing pulmonic component of the 2nd heart sound, wheezing, hypotension, cyanosis, pleural rub, raised jugular venous pressure
- PE should be suspected in cases of postoperative hypoxemia
Pleuritic Chest Pain
- Pleuritic chest pain with or without dyspnea is one of the most frequent presentations of PE
- May suggest a small embolism located distally near the pleura that also causes pleural irritation
Isolated Dyspnea
- Isolated dyspnea may occur suddenly or progressively (over several weeks)
- Usually due to a more central PE (not affecting the pleura)
- May be associated with substernal angina-like chest pain that probably is representing right ventricular (RV) ischemia
- Worsening dyspnea may be the only symptom that indicates PE in patients with preexisting heart failure (HF) or pulmonary disease
Syncope or Shock
- Syncope or shock is the hallmark sign of central PE and usually results in severe hemodynamic repercussions
- Signs of hemodynamic compromise and reduced heart flow are also usually present (eg systemic arterial hypotension, oliguria, cold extremities and/or clinical signs of acute right heart failure)
Massive Pulmonary Embolism
- Dyspnea is usually the prime symptom and systemic arterial hypotension that requires pressor support is the predominant sign
- Persistent hypotension is defined as a systolic blood pressure (SBP) <90 mmHg or a pressure drop of <40 mmHg for >15 minutes (or needing inotropic support) not caused by new-onset arrhythmia, hypovolemia or sepsis; or absence of pulse or sustained heart rate <40 beats/minute (bpm) with signs or symptoms of shock
- Syncope and altered mentation
- Renal insufficiency, hepatic dysfunction
- Severe respiratory distress or hypoxemia (eg cyanosis)
Risk Factors
Transient or Reversible Provoking
- Surgery within the past 4 weeks (eg hip or knee replacement)
- Major trauma
- Immobilization for at least 3 days
- Bedridden for >3 days
- Estrogen therapy
- Pregnancy/postpartum
- Lengthy travel, eg airline flight >8 hours
Persistent Provoking
- Active cancer
- Active autoimmune disease
- Antiphospholipid antibody syndrome
- Chronic inflammatory states, eg inflammatory bowel disease
Other Risk Factors
- Increasing age
- Past medical history or family history of VTE
- Spinal cord injury
- Lower limb fracture
- Myocardial infarction or hospitalization for atrial flutter/fibrillation or heart failure within the past 3 months
- Congestive heart failure or respiratory failure
- Obesity
- Varicose veins
- Blood transfusion and erythropoiesis-stimulating agents