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1. Management of Deep Vein
Thrombosis and Pulmonary Embolism
Sunil Kumar Daha

3. Treatment
ANTICOAGULATION
• low-molecular-weight heparin (LMWH), or
fondaparinux is used
• Warfarin

4. • Low-Molecular-Weight Heparins
– Greater bioavailability
– More predictable dose response, and a longer half-
life than does UFH
– No monitoring or dose adjustment required
– Adult 7500 -10000 IU followed by 1000 – 1500 IU/ hr
in infusion
– Child 50-100 U/kg

5. • Fondaparinux
– An anti-Xa pentasaccharide
– Administered as a once-daily subcutaneous
– No laboratory monitoring is required.
– Patients weighing <50 kg receive 5 mg, patients
weighing 50–100 kg receive 7.5 mg, and patients
weighing >100 kg receive 10 mg

6. Warfarin
• Vitamin K antagonist
• Prevents carboxylation activation of coagulation
factors II, VII, IX, and X.
• Requires at least 5 days to act fully
• Usually initiated in a dose of 10 mg in first and
second day, on 3rd day 5 mg subsequent doses is
titratedd against the INR
• Doses of 7.5 or 10 mg can be used in obese
patients
• When heparin is coumarin with warfarin it is
monitored by INR target to 2.5 to 3 for two days,
then after stop heparin.

7. Pulmonary embolism due to DVT

9. Acute management
• Oxygen- to hypoxemic patient until SpO2 is
more than 90%
• IV fluids and plasma - for circulatory shock
• Resuscitation by external cardiac massage
• Avoids diuretics and vasodilators
• Opiates for relieving pain and distress but
should be used with caution in hypotensive
patient

10. Treatment
ANTICOAGULATION
• low-molecular-weight heparin (LMWH), or
fondaparinux is used
• Warfarin
• If proven or suspected heparin-induced
thrombocytopenia ,a direct thrombin
inhibitor—argatroban, lepirudin, or bivalirudin is
used

11. Newer anticoagulants
• Rivaroxaban, a factor Xa inhibitor, and
dabigatran, a direct thrombin inhibitor are
used for prevention of VTE
• Have rapid onset of action and relatively short
half-life so“bridging” with a parenteral
anticoagulant is not required
• Does not require laboratory monitoring
• Have less drug-drug or drug-food interactions

12. Duration of anticoagulant therapy
• If identifiable risk factors are present,
anticoagulant can be discontinued after 3 months
• If persistant prothrombotic risks or previous
history of emboli, should be anticoagulated for
life
• If cancer associated VTE, heparin should be given
for 6 months

13. INFERIOR VENA CAVAL (IVC) FILTERS
The indications are:
• Active bleeding that precludes anticoagulation
• Recurrent venous thrombosis despite intensive
anticoagulation
• Prevention of recurrent PE in patients with right heart
failure who are not candidates for fibrinolysis
Disadvantages:
• May fail by permitting the passage of small- to
medium-size clots
• Large thrombi may embolize to the pulmonary arteries
via collateral veins that develop
• Caval thrombosis with marked bilateral leg swelling

14. Fibrinolysis
Indication: Massive pulmonary embolism
• It
– Dissolves obstructing pulmonary arterial thrombus
– Prevents continued release of serotonin and other
neurohumoral factors that exacerbate pulmonary
hypertension
– Lyses the source of the thrombus in the pelvic or deep leg
veins
• 100 mg of recombinant tissue plasminogen activator
(tPA) administered as a continuous peripheral
intravenous infusion over 2 hours.
• Contraindications : Intracranial disease,recent surgery,
and trauma

15. Surgical intervention
1. Pulmonary embolectomy
2. Pulmonary thromboendarterectomy
• Indication: Patients impaired by dyspnea due
to chronic thromboembolic pulmonary
hypertension

16. References
• Davidson’s Principles and Practice of Medicine
22nd edition
• Harrison’s Principal of internal medicine, 19th
edition
• Kumar and Clark's, Clinical Medicine, 8th Edition
• Essential Medical pharmacology, KD Tripathi,
6th edition

17. Thank You