3 years ago one of my patient arriving from England on a European airline was found to be breathless on arrival in Singapore. Although the airport doctor treat her for her breathlessness with oxygen, she did not feel better. Her younger brother brought her to my clinic because of breathlessness. I asked whether she has pain in the leg region. Indeed she has a warm red painful swollen vein on the left side of her calf region.
She was suspected to have a deep vein thrombosis with pulmonary embolism and was immediately treated with intravenous heparin and oral aspirin with almost immediate relief of her symptoms. She was continued on the oral aspirin and told to raise her legs. After the few days the swelling of the leg also disappeared confirming the presence of DVT. In the ideal situation an ultrasound of her veins should be done to confirm the DVT.
In this case because of the presence of early pulmonary embolism treatment was started immediately and her condition was relieved dramatically.
Deep vein thrombosis (DVT) is a blood clot (thrombus) in a deep vein leading to the heart, usually in the legs.The blood clot may either block the vein completely or partially.
It is more common in the elderly and the obese.
Women are more prone to it.
Blood Clots can form in superficial veins (called superficial thrombophlebitis or phlebitis) and in deep veins due to poor blood flow or stasis.
Blood clots in superficial veins rarely cause serious problems.
Blood clots in deep veins (deep vein thrombosis) require immediate medical care.
These clots are dangerous because they can break loose and then travel through the bloodstream to the lungs, causing a pulmonary embolism(Blockage of a pulmonary artery resulting in damage to the lung supplied by it).
A pulmonary embolism is often life-threatening.
Blood clots most often develop in the calf and thigh veins, and less often in the arm veins or pelvic veins.
3 major factors play a part in the development of DVT.
1.Venous stasis i.e. the pooling of blood in the veins. This may be the result of immobility, old age or heart failure.
2.Damage of the vein due to trauma or local pressure.
Surgery or an injury can damage your blood vessels and cause a clot to form.
3.Increased coagulability (tendency of blood to clot) of the blood which is sometimes seen in clotting disorders, pregnancy, the use of oral contraceptives, dehydration or in some cancers.
Sitting for long periods without exercising your leg muscles is a main factor. Passengers in first class seats in a plane have been known to develop DVT.
Similarly, DVT has been seen in students sitting for many hours preparing for exams.
Blood clots can form in veins when you are inactive.
For example, clots can form if you are paralyzed or bedridden or must sit while on a long flight or car trip. Some people have blood that clots too easily, a problem that may run in families.
Symptoms of DVT include :
1.Pain and tenderness of the affected limb which may become worse especially when standing
2.Swelling of the affected limb
3.Redness and warmth of the area surrounding the blood clot.
If a blood clot is small, it may not cause symptoms.
These symptoms may not be present immediately the clot is formed.
Sometimes it may take up to 2 weeks before the symptoms became apparent.
In some cases, pulmonary embolism is the first sign that you have DVT.
1.If there is any suspicion that you have DVT, you probably will have an ultrasound test within 24 hours to measure the blood flow through your veins and help find any clots that might be blocking the flow. Unless done within 24 hours, an ultrasound may or may not be able to detect the blood clot .However it is useful in measuring the blood flow through your vein.
2.A venogram is the most accurate of all the tests. However because it requires a doctor to administer it and is invasive unlike an ultrasound, it is only done if ultrasound results are unclear. A venogram is an X-ray test that takes pictures of the blood flow through the veins.
3.Other tests like a MRI will also be able to show the blood clot and the flow of the blood in the vein. Like the ultrasound , it must be done early in order to detect any blood clot.
Treatment must start right away to reduce the chance that the blood clot will grow or that a piece of the clot might break loose and flow to your lungs.
Treatment for DVT usually involves taking blood thinners (anticoagulants) such as heparin and warfarin.
Heparin is given through a vein (intravenously, or IV) or as an injection.
Warfarin is given as a pill.
Treatment usually involves taking blood thinners for at least 3 months to prevent existing clots from growing.
Anti-coagulants - these are agents which prevent further clot formation and thins the blood. Examples are Heparin injection, warfarin, Plavix, Ticlid, Aspirin
Thrombolytic agents - these are agents which dissolve clots that have already formed. Examples are streptokinase, tPA.
After this first course of blood thinners, your doctor may want you to keep taking a lower dose of warfarin to prevent deep vein clots from happening again. He may need to adjust the dose of your medicine or change the medicine to a lighter blood thinner like Aspirin.
You may need to have blood tests often to see how well the blood thinners are working.
It is also recommended that you
prop up or elevate your leg when possible,
use a heating pad,
take walks, and
wear tight-fitting stockings.
These measures may help reduce the pain and swelling that can happen with DVT.
Rarely a vena cava filter may be inserted into a vein to help prevent blood clots from traveling to the lungs. This device is usually only used if a person is at high risk for pulmonary embolism and is not able to take blood thinners.
It may also be used if you have DVT that comes back again or you had a pulmonary embolism while taking blood thinners.
Deep vein thrombosis in itself is not that serious. The danger occurs when the blood clot or a part of it breaks off and travels to the lungs where it can block an artery. This complication is called pulmonary embolism. It is a life-threatening situation and often ends in fatalities. Emergency medical attention is imperative.
Dislodged clots can travel to other areas and cause stroke or damage to organs depending on where they get lodged.
DVT can also cause long-lasting problems.
DVT may damage the vein and cause the leg to ache, swell, and change color.
It can also cause leg sores.
There are things you can do to prevent deep vein thrombosis.
Many doctors recommend that you
1.wear compression stockings during a journey longer than 8 hours.
2. avoid sitting in a cramped position for too long
3.Wriggle your toes and move your ankles and knees
4.Massage muscles of the lower limbs
5.Don't cross your legs or sit on the edge of your seat
6.Get up and walk along the aisle at least once an hour
7.Wear loose clothing
8.Avoid stockings or socks with tight bands
9.Drink plenty of water
10.Avoid alcohol and caffeine
11.Don't smoke
12.Wear special support stockings designed for traveling
On long flights, walk up and down the aisle hourly, flex and point your feet every 20 minutes while sitting, drink plenty of water, and avoid alcohol and beverages with caffeine.
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