1. PE & DVT treatment

2. Classification of Emboli - Fat and Marrow ◦Sequelae from any marrow/adipose injury ◦fat and cells are released into bloodstream ◦CPR, long bone fractures, setting of soft tissue or burns.

3. Air ◦Clinical effect: >100 cc air ◦Air coalesce  frothy masses ◦Introduced via surgical procedures, e.g. Laparoscopic, obstetric, bypass ◦Decompression sickness: deep sea divers, underwater workers.

4. Amniotic Fluid ◦Amniotic fluid/fetal tissue in maternal circulation ◦Originates at tears of placental membranes or rupture of uterine veins. ◦5 th most common cause of maternal mortality

5. Tx of DVT Goals: ◦prevent clot propagation ◦Prevent pulmonary hypertension ◦recurrence of clot Tx: anticoagulant therapy + warfarin 6-12 weeks ◦Non-pharm measures: leg elevation, heat application, compression stockings ◦Can treat with outpatient based (except PE)

6. Tx of PE 1. oxygen 100% 2. morphine IV if pain/distressed 3. Massive PE: thrombolysis/surgery 4. IV  heparin as guided by APTT 5. Systolic BP ◦>90mmHg: warfarin  confirm Dx PE ◦<90mmHg:colloid infusion  noradrenaline  consider thrombolysis (if not step 3)

7. Anticoagulant Therapy Delay in Dx: treat presumptively Contraindications: intracranial bleeding, severe active bleeding, recent brain, eye, or spinal cord surgery, and malignant hypertension Heparin ◦Activates antithrombin to II, VII, IX, X, XI, XII Warfarin ◦Inhibits reductase to activate Vit K – cofactor of cascade

8. Unfractionated Heparin Pros ◦Cheaper ◦Use for patients with renal insufficiency/failure ◦Indicated for submassive/massive PE ADR: ◦Thrombocytopenia (transient 10-20%), major bleeding (2%) ◦Risk: >65yrs, recent surgery, liver disease

9. Low Molecular Weight Heparin LMWH (Fractionated Heparin) ◦more predictable anticoagulant effects ◦does not require blood monitoring ◦outpatient therapy ◦Longer half-life ◦Subcutaneous admin. ◦ADRs of UF less likely

10. Warfarin Therapy starts when acute anticoagulation is achieved starting Tx at 5 mg per day Titrating the dosage every 3-7 days to achieve an INR between 2.0 and 3.0 ◦E.g. Day 3 INR <3 10 mg/day or INR <2.0-2.9 2.5 mg/day

11. Thrombolytic Therapy Not used for DVTs Used when anticoagulant therapy fails Indicated for massive PE Include: streptokinase, tPA via IV

12. Surgical Therapy A transvenous catheter embolectomy or open surgical embolectomy Indications: ◦thrombolytic therapy fails ◦Contraindicated for thrombolytic therapy ◦Massive PE + refractory hypotension Vena cava filters for recurrent PEs ◦Combined with anticoagulation therapy

13. Management Prevent further thrombosis Heparin + warfarin for ≥5 days. ◦Stop heparin at INR>2. Warfarin therapy depends on underlying cause, vary from 3-6 months or indefinite. Warfarin is contraindicated in pregnant women, use LWMH instead.