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  #1  
Old 06-08-2012
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Question DVT Management, what's after Heparin?

You are asked to evaluate a 62-year-old man on the orthopedic surgery service for shortness of breath. The patient was initially admitted to the hospital 14 days ago for a right hip fracture and successfully underwent hip replacement surgery 12 days ago. He required treatment for congestive heart failure secondary to excessive postoperative fluid resuscitation. Three days ago, he once again developed shortness of breath and has been progressively worsening without a response to diuretics.
The patient is tachypneic but able to complete sentences. His blood pressure is 137/83 mm Hg, respiratory rate is 26/min, and his heart rate is 108/min. An arterial blood gas on a 50% facemask shows a pH of 7.38, a pCO2 of 30 mm Hg, a pO2 of 72 mm Hg, and a saturation of 90%. The chest x-ray shows mild right basilar atelectasis without signs of congestion. The EKG shows sinus tachycardia with left ventricular hypertrophy, although there is right axis deviation. An echocardiogram estimates the pulmonary artery systolic pressure at 45 mm Hg. The venous duplex reveals bilateral chronic and acute nonocclusive femoral and popliteal thrombi with freely mobile clots. Intravenous heparin is started. What is the most urgent step in the management of this patient?
(A) Spiral CT scan of the chest
(B) V/Q scan
(C) Intubate and place the patient on mechanical ventilation
(D) Inferior vena cava filter placement
(E) Initiate coumadin therapy
(F) Embolectomy
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Old 06-09-2012
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The way the question ask "what is the most urgent way" is suspicious !!
I will go the adding warfarin .
what about freely moving clots in leg veins ??? Shall we do anything about them !!
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Old 06-09-2012
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Quote:
Originally Posted by bisho View Post
The way the question ask "what is the most urgent way" is suspicious !!
I will go the adding warfarin .
what about freely moving clots in leg veins ??? Shall we do anything about them !!
I would go with,

(D) Inferior vena cava filter placement

This pt is symptomatic but not in severe distress, so doesn't need embolectomy.
This pt would eventually need to be shifted on warfarin but i dont think this is an urgent matter.
Another episode of PE in this pt would be fatal, so its better to put an IVC filter in this pt. and also as bisho said we need to do something about the moving clots.
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Quote:
Originally Posted by step1an View Post
I would go with,

(D) Inferior vena cava filter placement

This pt is symptomatic but not in severe distress, so doesn't need embolectomy.
This pt would eventually need to be shifted on warfarin but i dont think this is an urgent matter.
Another episode of PE in this pt would be fatal, so its better to put an IVC filter in this pt. and also as bisho said we need to do something about the moving clots.
this is correct ans and correct explanation.

btw, isnt heparin enough to prevent further clots.

@bisho, warfarin is not started that acutely. typically, 5 days heparin cover is needed and warfarin is started if target INR is achieved. so it should not be urgent step. thoughts?
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So IVCF is indicated if the pt
-had contraindication to anticog
-recurrent thrombosis despite anticog
-free floating thrombi detected on leg US after anticog !!! Can we say that

@tyagee warfarin is usually initiated at the same time with hep, and when INR achieve therapeutic level i.e 2-3 we stop hep, INR is reflection of warfarin not hep
aPTT; for hep
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Old 06-09-2012
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answer is warfarin, as there is no indication of IVC placement in the above case and we will start warfarin simultaneously with heparin and once we reach therapeutic INR(2-3), approx after 5 to 6 day we will DC heparin and continue with warfarin for 6 months

Quote:
Originally Posted by bisho View Post
So IVCF is indicated if the pt
-had contraindication to anticog
-recurrent thrombosis despite anticog
-free floating thrombi detected on leg US after anticog !!! Can we say that

@tyagee warfarin is usually initiated at the same time with hep, and when INR achieve therapeutic level i.e 2-3 we stop hep, INR is reflection of warfarin not hep
aPTT; for hep
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Old 06-09-2012
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Quote:
Originally Posted by bisho View Post
So IVCF is indicated if the pt
-had contraindication to anticog
-recurrent thrombosis despite anticog
-free floating thrombi detected on leg US after anticog !!! Can we say that

@tyagee warfarin is usually initiated at the same time with hep, and when INR achieve therapeutic level i.e 2-3 we stop hep, INR is reflection of warfarin not hep
aPTT; for hep
my bad!

this is qbank explan

(D) Inferior vena cava filter placement
Explanation:
The patient has developed pulmonary emboli from the proximal venous
thrombi in the leg as suggested by tachypnea, tachycardia, and a wide A-a
gradient on the blood gas. There is clear evidence of a source of the emboli
on venous Doppler studies of the lower extremities. The next best step in
the management of this patient is to prevent further embolization, therefore
justifying the emergent placement of an intracaval filter.
Although the
diagnosis of pulmonary embolism with spiral CT or V-Q scanning would be
helpful in validating the use of anticoagulation, they would not be useful for
stabilizing the patient at this time. In addition, the weight of evidence for a
pulmonary embolus is so overwhelming in this patient that even if the V/Q
scan were low probability for an embolus, you would still continue to treat
the patient anyway. These tests will not change your acute management.
Coumadin, although indicated, would not be effective in the immediate
treatment of this patient
. Although the patient is tachypneic, there does not
appear to be any signs of acute respiratory failure. For this reason, acute
intubation and mechanical ventilation are not warranted at this time. The
filter is the most urgent step here because of the high likelihood of
respiratory failure and hemodynamic instability if another clot occurs.
This
patient has pulmonary hypertension already, and although he is
oxygenating well now, another clot could be potentially fatal.
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