IPHREHAB : PULMONARY EMBOLISM

IPHREHAB


PULMONARY EMBOLISM:

• PAIN CHEST
• PAIN SEVERE RESEMBLE  LIKE THAT OF MYOCARDIAL INFARCTION 
• DYSPNOEA-SEVERE
• COUGH
• HAEMOPTYSIS
• PLEURAL RUB

PULMONARY EMBOLISM

Flight-related Deep Vein Thrombosis (DVT) 

• AN IMPORTANT ENTITY
• KNOWN AS “ECONOMY CLASS SUNDROME”
• SEEN IN PERSONS ON LONG DISTANCE TRAVEL
• OBESE,, OEDEMATOUS
• DEHYDRATED
• COAGULATION DISORDERS

INVESTIGATIONS

1. COMPLETE HAEMOGRAM
2. BT, CT, PROTHROMBIN TIME
3. VENOGRAPHY
4. CT SCAN
5. MRI SCAN
6. ULTRA SOUND- can localize the clot.

Prevention of Pulmonary Embolism

• RISK OF PULM.  EMBOLISM IN PROX DEEP VEIN THROMBOSIS IS  50%
• IN CALF VEIN THAROMBOSIS IS 5-20
• ANTOCOAGULANTS;-  Heparin 7500 Units IV initially, followed by 1000 Units hourly. Should be maintained for 5-7 day

PULMONARY EMBOLISM

• Heparin can be given SC and should be for 3-5 months
• THROMBOLYSIS:- Streptokinase, Urokinase can be used. They are less effective.
• Warfarin can be used also for long time

• LOW DOSE HEPARIN may be very helpful. 5000 Units twice daily SC. It is also helpful in preventing embolsm in Surgical cases.
• ASPIRIN in low doses is also very helpful

MANAGEMENT :

Preventive

• STAND UP & WALK
• CALF MUSCLE EXERCISES
• LOT OF FLUIDS
• NO ALCOHOL
• NO SMOKING
• AVOID CROSS LEGS IN POSTURE
• WEAR LOOSE CLOTHING

MANAGEMENT

• PHYSIOTHERAPY
• REDUCE WEIGHT
• ELEVATE YOUR LEGS
• STOCKINGS
• ROLE OF ASPIRIN
• LOW DOSE HEPARIN
• WARFARIN

CONCLUSIONS

• DVT is very common condition
• It is common in elderly diabetic especially travelling by air on long flights
• IN USA 600,000 cases are diagnosed  every year
• 1% can lead to Pulm.Embolism
•  Pulm. Embolism  may be fatal
• It is Preventable
• Exercise & anticoagulant play important part.

IPHREHAB : DEEP VEIN THROMBOSIS

IPHREHAB

DEEP VEIN THROMBOSIS

DEFINITION

It is characterized by formation of clots in deep veins of body

It is more common in lower limbs and thighs

It is dangerous condition- clot can detach and lead to pulmonary embolism

Early detection is must to prevent this complication 

PREVELANCE : 

• IT IS VERY COMMON CONDITION
• SECOND MOST COMMON CAUSE  OF VASCULAR PROBLEM
• IN USA  600,000 CASES ARE DIAGNOSED EVERY YEAR
• ONE IN 100 DIES OF PULMONARY EMBOLISM
• IT IS COMMON AFTER 60 YEARS

PERSONS AT RISK

• THE ELDERLY
• DIABETICS
• HAVING BLOOD DISEASES
• WOMEN ON ORAL CONTRACEPTIVES-Oesterogens
• HISTORY OF PREVIOUS THROMBOSIS
• MAJOR SURGERY

• HOSPITALIZED PATIENTS
• PERSONS ON PROLONGED BED REST (Persons confined to bed)
• IMMOBILISED PERSONS –Fracture Neck femur
• PASSENGERS ON LONG INTERNATIONAL FLIGHTS-(Economy Class Syndrome

PERSONS AT RISK

• PARALYSED CASES
• CANCER PATIENTS
• PREGNANCY & CHILD BIRTH
• CONGESTIVE FAILURE
• CIRCULATORY PROBLEMS

DEEP VEIN THROMBOSIS

CLINICAL PICTURE

Symptoms

1. Discoloration of the legs 
2. Calf or leg pain or tenderness 
3. Swelling or Oedema of the legs or both feet lo 
4. Warm skin 
5. Surface veins become more visible 
6. Leg fatigue
7. Pain worst on standing 

SIGNS

• PALPABLE THROMBOSED VEINS
• CALF TENDERNESS
• ECCHYMOSIS
• LIMBS ARE WARM
• CONSTITUTINAL SYMPTOMS
• PULMONARY EMBOLISM

Flight-related Deep Vein Thrombosis (DVT) 

• AN IMPORTANT ENTITY
• KNOWN AS “ECONOMY CLASS SUNDROME”
• SEEN IN PERSONS ON LONG DISTANCE TRAVEL
• OBESE,, OEDEMATOUS
• DEHYDRATED
• COAGULATION DISORDERS

MANAGEMENT  :

Preventive

• PHYSIOTHERAPY VERY EFFECTIVE
• STAND UP & WALK
• CALF MUSCLE EXERCISES
• LOT OF FLUIDS
• NO ALCOHOL
• NO SMOKING
• AVOID CROSS LEGS IN POSTURE
• WEAR LOOSE CLOTHING

MANAGEMENT

• REDUCE WEIGHT
• ELEVATE YOUR LEGS
• STOCKINGS
• ROLE OF ASPIRIN
• LOW DOSE HEPARIN
• WARFARIN

IPHREHAB : DIFFERENTIAL DIAGNOSIS AND TREATMENT CEREBRAL THROMBOSIS AND TIAs

IPHREHAB

DIFFERENTIAL DIAGNOSIS CEREBRAL THROMBOSIS AND TIA


Differential Diagnosis
Vascular disorders are mistaken for ischaemic stroke include intracerebral hemorrhage, subdural or epidural hematoma , and subarachnoid hemorrhage from rupture of an aneurysm or vascular malformation. These condition can often be distinguished by a history of trauma or of excruciating headache at onset, a more marked depression of consciousness, or by the presence of neck stiffness on examination. They can be excluded  by CT scan or MRI.


Differential Diagnosis: Other structural brain lesion such as tumor or abscess can also produce focal cerebral symptoms of acute onset. Brain abscess is suggested by concurrent fever, and both abscess and tumor can usually be diagnosed by CT scan or MRI. Metabolic disturbances, particularly hypoglycemia and hyperosmolar nonketotic hyperglycemia, may present in stroke like fashion. The serum glucose level should therefore be determined in all patients with apparent stroke.

Treatment of Cerebral Thrombosis and Transient Ischemic Attacks

The current treatment of it may be divided into four parts:

Management in the acute phase

Measures to restore the circulation and arrest the pathologic process

    1. Thrombolytic agents ( t-PA only for completed stroke,w/in 3~6hrs ) 2.Anticoagulant drugs ( Heparin, LMWH & warfarin)

    3. Antiplatelet drugs ( Aspirin  or  Clopidogrel, Dipyridamole or   Ticlopidine )

    4.Difibrase

    5. Neuroprotective agents: barbiturates, opioid  antagonist naloxone,Manitol

Treatment

Treatment of cerebral edema and raised intracranial pressure

Acute surgical revascularization 

Surgery for symptomatic carotid stenosis, Carotid endarterectomy, intralumenal stents, extracranial-intracranial bypass

Physical therapy and rehabilitation.

Measures to prevent further strokes and progression of vascular disease.

• Since the primary objective in the treatment  of  atherothrombotic disease is prevention , efforts to control the risk factors must continue. 
• Aspirin
• Hypotensive agents
• Oversedation should be avoided
• Systemic hypotension, severe anemia should be treated promptly
• Particular care should be taken to maintain the systemic blood pressure, oxygenation  and intracranial  blood flow during surgical procedures, especially in elderly patient.

Course and Prognosis

When the patient is seen early in the cerebral thrombosis, it is difficult to give an accurate prognosis.

As for the eventual or long-term prognosis of the neurologic deficit , there are many possibilities.

It must be mentioned that having had one thrombotic stroke, the patient is at risk in the ensuing months and years of having a stroke at the same or another site, especially if there is hypertension or diabetes mellitus.

IPHREHAB : Transient Ischemic Attacks(TIA) & CEREBRAL THROMBOSIS

IPHREHAB

1.Transient Ischemic Attacks(TIA)
Current opinion holds that TIAs are brief, reversible episodes of focal, nonconvulsive ischaemic neurologic disturbance, Consensus has been that their duration should be less than 24 h.

Clinical picture
Transient Ischaemic Attacks can reflect the involvement of any cerebral artery. The loss of function entirely depends on the influenced artery. It may last  a  few seconds or up to 12 to 24 h, Most of them last 2 to 15 min. There are only a few attacks or several hundred. Between attacks, the neurologic examination may disclose no abnormalities. A stroke may occur after numerous attacks have occurred over a period of weeks or months.

Differential diagnosis of TIAs

Transient episodes, indistinguishable from TIAs, are known to occur in patients with Seizure,Migraine,Transient global amnesia,and occasionally in patients with multiple sclerosis, meningioma, glioblastoma ,metastatic brain tumors situated in or near the cortex ,and even with subdural hematoma.

2. Cerebral thrombosis

Most cerebrovascular disease can be attributed to atheroscleroses and chronic hypertension; until ways are found to prevent or control them, vascular disease of the brain will continue to be a major cause of morbidity.

Pathogenesis

Pathogenesis of Ischemic neuronal death

   Ischemia

       ↓ 

   Excitatory amino acid receptors

       ↓ 

   Borderzone or penumbra    ↓

   Programmed cell death

Clinical picture  

In general, evolution of the clinical phenomena in relation to cerebral thrombosis is more variable than that of embolism and hemorrhage. The loss of function that the patient notices, and which may be apparent on examination, entirely depends on the area of brain tissue involved in the ischaemic process.

Clinical picture

In more than half of  patients, the main part of the stroke is preceded by minor signs or one or more transient attacks of focal neurologic dysfunction. The final stroke may be preceded by one or two attacks or a hundred or more brief TIAs, and stroke may follow the onset of the attacks by hours, weeks, or, rarely, months.

The most occurrence of the thrombotic stroke is during sleep.The patient awakens paralyzed. Either during the night or in the morning.

Unaware of any difficulty, he may arise and fall helplessly to the floor with the first step.

Clinical picture

Associated symptoms

Seizures accompany the onset of stroke in a small number of cases (10-50%); in other instances, they follow the stroke by weeks to years. The presence of seizures does not definitively distinguish embolic from thrombotic strokes, but seizure at the onset of  stroke may be more common with embolus.

Headache  occurs in about 25% of patients with ischaemic stroke, possibly because of the acute dilation of collateral vessels.

Laboratory Findings

• CT Scan or MRI: A CT scan or MRI  should be obtained routinely to distinguish between infarction and hemorrhage as the cause of stroke, to exclude other lesions (eg, tumor, abscess) that can mimic stroke, and to localize the lesion. CT is usually preferred for initial diagnosis because it is widely available and rapid and can readily make the critical distinction between ischaemia and hemorrhage.
• Lumbar Puncture: This should be performed in selected cases to exclude subarachnoid hemorrhage.
• Cerebral Angiography: Intra-arterial angiography is used to identify operable extracranial carotid lesions in patients with anterior circulation TIAs who are good surgical candidates. It also can be used for intra-arterial thrombolysis ( r-tPA)
• Magnetic resonance  Angiography (MRA) may detect stenosis of large cerebral arteries, aneurysms, and other vascular lesion, but its sensitivity is generally inferior to that of conventional angiography.