Venous Thromboembolism (VTE) – Initial Management

Meagan Wong, MD
Brandon Fainstad, MD
David Garcia, MD – expert review (hematologist, University of Washington)


OBJECTIVES
1. Determine IF a venous thromboembolus warrants anticoagulation versus further evaluation.
2. Determine WHERE anticoagulation should be initiated, inpatient or outpatient.
3. Select WHICH anticoagulation agent to use.
4. Develop a framework for determining HOW LONG to anticoagulate.


TEACHING INSTRUCTIONS


INTRODUCTION
Initial management of venous thromboemboli (VTE) depends on vascular location, an individual’s ongoing thrombosis risk and their risk of bleeding. We will work through four separate cases and in the process, answer four basic questions: 1. IF the thrombus should be treated with anti-coagulation, 2. WHERE the anti-coagulation should be initiated, 3. WHAT is the most appropriate long-term agent and 4. HOW LONG to anti-coagulate.


CHALK TALK
Board Set-up:


Stage 1 – IF (immediate anti-coagulation)?

Case A
A 45-year-old man involved in a motor vehicle accident suffers a right humerus fracture and multiple rib fractures along with a tension pneumothorax. He is admitted to the surgical ICU following surgery and chest tube placement. On hospital day five, the anticipated day of discharge, he is noted to have a slightly swollen ankle. A venous duplex study reveals an acute 2cm non-occlusive DVT in his posterior tibial vein without any proximal thrombi identified. He is ambulating independently and expected to spend the majority of the day out of bed over the subsequent weeks.

How would you classify this VTE? Do you want to initiate anticoagulation?

Case B

An 82-year-old man with COPD and recent diverticular bleed presents to the ED with increased shortness of breath and left-sided pleuritic chest pain. HR is 95bpm, BP 120/80 and SpO2 92%. His ECG reveals sinus tachycardia and CXR with slightly increased lung volumes but otherwise unremarkable. He is found to have multiple left-sided segmental PEs on a chest CTA. He denies any recent history of prolonged travel, surgery or immobility.

How would you define this VTE? Do you want to initiate anticoagulation?

Case C

A 38-year-old woman presents to the ED with three days of right-sided chest pain and shortness of breath. She is afebrile, HR 100bpm, BP 110/75, SpO2 94%. Her CXR, ECG, and troponins are unremarkable. A CT PE reveals two sub-segmental PEs in the right lower lung base. When asked, she admits to possibly having slight swelling in her right leg last week. She denies any recent history of prolonged travel, immobilization or surgery. She is pre-menopausal and not on hormonal birth control. Her mother had an unprovoked VTE at age 48, it is unknown if she has an inheritable hypercoagulation mutation.

How would you define this VTE? Do you want to initiate anticoagulation?

Case D

A 65-year-old man with prostate cancer metastatic to his spine presents to clinic with increased swelling and mild pain in his LEFT leg over the past week. The RIGHT leg is unchanged, and he is still able to walk on both feet. He denies shortness of breath, orthopnea/PND, significant weight gain, fevers or chills. He lives with his wife who is healthy and available to take care of him 24/7. A lower extremity duplex reveals an acute occlussive DVT in the left common femoral vein.

How would you define this VTE? Do you want to initiate anticoagulation?


Stage 2 – WHERE (to initiate treatment)?

Case B?

Case C?

Case D?


Stage 3 – WHICH (anticoagulation agent)?


Stage 4 – HOW LONG (to treat)?

Case B?

Case C?

Case D?


Final Board


TAKE HOME POINTS

REFERENCES

Kearon, Clive, et al. “Antithrombotic Therapy for VTE Disease.” Chest, vol. 149, no. 2, 2016, pp. 315–352., doi:10.1016/j.chest.2015.11.026.

Aujesky, Drahomir, et al. “Derivation and Validation of a Prognostic Model for Pulmonary Embolism.” American Journal of Respiratory and Critical Care Medicine, vol. 172, no. 8, 2005, pp. 1041–1046., doi:10.1164/rccm.200506-862oc.

Stevens, Scott M., et al. “Guidance for the Evaluation and Treatment of Hereditary and Acquired Thrombophilia.” Journal of Thrombosis and Thrombolysis, vol. 41, no. 1, 2016, pp. 154–164., doi:10.1007/s11239-015-1316-1.

Raskob, G. E., et al. “Edoxaban for the Treatment of Cancer-Associated Venous Thromboembolism.” New England Journal of Medicine,378(7), 2018, pp. 615-624. doi:10.1056/nejmoa1711948

Young, Annie M., et al. “Comparison of an Oral Factor Xa Inhibitor With Low Molecular Weight Heparin in Patients With Cancer With Venous Thromboembolism: Results of a Randomized Trial (SELECT-D).” Journal of Clinical Oncology, vol. 36, no. 20, Oct. 2018, pp. 2017–2023., doi:10.1200/jco.2018.78.8034.

Wide Complex Tachycardia

Nathan Cade, MD
Brandon Fainstad, MD
Andrew Prouse, MD


OBJECTIVES
1. Identify the basic electrophysiology of the four causes of wide complex tachycardia.
2. Develop a simple framework for acute management of wide complex tachycardia.
3. Practice three cases with ECGs to differentiate ventricular tachycardia from other causes and determine the correct initial management.


TEACHING INSTRUCTIONS


INTRODUCTION
Wide complex tachycardias are uniquely challenging due to the difficulty in interpreting the ECG and the need for immediate management.  Fortunately, there are only a handful of potential rhythms and a few options for management.   If you remember nothing else, remember this:

  1. Unstable -> SHOCK (synchronized cardioversion)
  2. Stable ->
    1. Place defibrillation pads
    2. If regular and monomorphic, attempt vagal maneuvers or adenosine
    3. If it is irregular and suspicious for atrial fibrillation with aberrancy, attempt rate control
    4. If it doesn’t work, consciously sedate and cardiovert.
    5. If conscious sedation is not a safe option, try procainamide.

CHALK TALK – 15 min
Board Set-up:

Stage 1 – Electrophysiology

Stage 2 – Management

Final Board


PRACTICE CASES – 10-15 min

Case 1
A 65-year-old man with a recent MI presents to the ED complaining of palpitations. He is cognitively intact without lightheadedness and has palpable pulses.

Courtesy of Andrew Prouse, MD

What is the rhythm?
How do you want to manage it?

Case 2
26-year-old male with chest pain and SOB and no history of structural heart disease. Hemodynamically stable.

Adapted with permission of Dr. Smith’s ECG blog, http://hqmeded-ecg.blogspot.com/

What is the rhythm?
How do you want to manage it?

Case 3
A 60-year-old woman presents to the ED with fever, cough, and shortness of breath found to have the following ECG. She is tachycardic but has a normal blood pressure and cognitively intact. There is no prior ECG available for comparison.

Adapted with permission from Dr. Smiths ECG Blog (http://hqmeded-ecg.blogspot.com)

What is the rhythm?
How do you want to manage it?


TAKE HOME POINTS


REFERENCES

Ortiz M et al. Randomized Comparison of Intravenous Procainamide vs. Intravenous Amiodarone for the Acute Treatment of Tolerated Wide QRS Tachycardia: the PROCAMIO Study. Eur Heart J 2016.

Smith, Stephen W. “An Irregularly Irregular Wide Complex Tachycardia.” Dr. Smith’s ECG Blog, Aug. 2017, hqmeded-ecg.blogspot.com/.

Lazoff, Marjorie, et al. “VT versus SVT with Aberrancy.” LITFL • Life in the Fast Lane Medical Blog, 3 Sept. 2018, lifeinthefastlane.com/.

Garner, John B, and John M Miller. “Wide Complex Tachycardia – Ventricular Tachycardia or Not Ventricular Tachycardia, That Remains the Question.” Arrhythmia & Electrophysiology Review, vol. 2, no. 1, 2013, p. 23., doi:10.15420/aer.2013.2.1.23.