Episode 23: Blood Clots: DVT
The sun rises over the San Joaquin Valley, California, today is August 14, 2020.
Pain relief is a task that always keeps doctors very busy, especially if pain relief can be accomplished by a medication that is easily-administered, given at a convenient frequency, with no adverse effects, and with no addiction potential (specially to fight the so-called “opioid epidemic”). And if that medication contributes to healing the pain-causing condition, then that’s a perfect medication for pain relief. As a result of that endless search for a perfect pain reliever, the University of Southern California Health Sciences presented a new study on July 13, 2020, revealing that kappa opioids, a significantly less addictive opioid, may both preserve cartilage in joints and also ease pain in osteoarthritis (1). Sorry UCLA, we have to accentuate the positive regardless of the source. Go Bruins!
On August 11, 2020, we woke up to the news that Russia’s government registered the first COVID 19 vaccine in the world. President Vladimir Putin stated that his own daughter was inoculated with the vaccine and “she is feeling well and has high number of antibodies”. While some celebrated the Russian “big step for humanity”, some experts expressed concerns about safety, including the World Health Organization, warning Russia to adhere to standard protocols for testing a vaccine (2).
Coronavirus has brought more than a disease to the world, it has brought extensive material for political debate and controversy. There is a joke that circulated in social media that may be relevant in this case: A patient asks her doctor, “When will this coronavirus be over?”, and the doctor answers, “I don’t know, I’m not that involved in politics”. We hope humanity steps up and joins forces to overcome this devastating disease.
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Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.
The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve.
Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971.
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“[As doctors, let’s], never forget that we have the opportunity to do more good in one day than most people have in a month."― Dr. Suneel Dhand
Dear residents, how many opportunities did you have to do good today? It’s a great privilege to be instruments to relief pain, find a solution, and bring peace and happiness to your fellow men. It’s really a privilege. We have today an experienced doctor with whom I’ve had multiple conversations, and I’m very happy for having him in our residency program. Welcome, Dr Gonzalez.
Question Number 1: Who are you?
My name is Alejandro Gonzalez Perez, I am a second-year resident in the Rio Bravo Family Medicine Residency Program here in Clinica Sierra Vista, Bakersfield, California. I was born in Cuba where I finished medical school and completed a medical residency in Family medicine, and then a residency in Radiology. I am a father of three children, two boys and one girl. I enjoy spending time with my family and friends. My favorite music: Latin music. Favorite sport: I like to go to the gym but I enjoy seeing martial art combats. Favorite movies: action, fiction, and martial arts.
Comment: I recently watched The Karate Kid in Netflix, it’s a good show, and they’ll have a sequel in Netflix this month with the same actors of the original movie.
Question number 2: What did you learn this week?
Currently I’m on the Cardiology rotation. My number one goal in this rotation is optimize treatment for patients in the inpatient and outpatient settings. For example, I am learning how to better handle medication for Heart failure, CAD, HTN, and arrhythmias. And, almost all the patients have combined diagnosis, so you need to select the appropriate medication for HF with CAD, or HF combined with CAD and HTN, or HF with Afib, etc.
In addition, my knowledge about diagnostic tests has improved, ECG, Echocardiogram, Cardiac Cath, troponin management. Also, I have learned how to improve the interactions between different services in the hospital. I hadn’t had a previous rotation with Internal Medicine, but in this rotation, I’m spending time with some IM residents, and it’s been positive for me.
Venous thromboembolism (VTE)
VTE refers to a blood clot that starts in a vein. It is the third leading vascular diagnosis after heart attack and stroke, affecting between 300,000 to 600,000 Americans each year. The mos common presentations are: Deep vein thrombosis (DVT) of the lower extremity and pulmonary embolism (PE).
Pathophysiology
The Virchow's triad proposes that VTE is a result of three conditions: Alterations in blood flow (i.e., stasis), Vascular endothelial injury, and Alterations in the constituents of the blood.
The causes of venous thrombosis can be divided into two groups: hereditary and acquired.
Hereditary causes: Factor V Leiden mutation, Prothrombin gene mutation, Protein S deficiency, Protein C deficiency, Antithrombin deficiency.
Acquired risk factors: Prior thrombotic event, recent major surgery, presence of a central venous catheter, trauma, immobilization, malignancy, pregnancy, the use of oral contraceptives or heparin, myeloproliferative disorders, antiphospholipid syndrome (APS), and a number of other major medical illnesses. Of note, a special risk factor is the s-called “Sitting Disease” which, broadly speaking, is defined as a condition of increased sedentary behavior associated with adverse health effects.
Provoked vs Unprovoked DVT
The term unprovoked deep vein thrombosis (DVT) implies that there is not an evident cause for DVT. In contrast, a provoked DVT is usually caused by a known event.
Proximal vs Distal DVT
Proximal DVT is located in the popliteal, femoral, or iliac veins. Isolated distal DVT has no proximal component, it is located below the knee, and is confined to the calf veins (peroneal, posterior, anterior tibial, and muscular veins)
Symptomatic vs Asymptomatic DVT
Symptomatic DVT refers to the presence of symptoms that usually leads to the radiologic confirmation of DVT, whereas asymptomatic DVT refers to the incidental finding of DVT on imaging in a patient without symptoms (eg, computed tomography).
Symptoms of DVT
Throbbing or cramping pain in 1 leg (rarely both legs), usually in the calf or thigh.
Swelling in 1 leg (rarely both legs)
Warm skin around the painful area.
Red or darkened skin around the painful area.
Swollen veins that are hard or sore when you touch them.
Diagnosis of DVT
Duplex ultrasonography: It can detect blockages or blood clots in the deep veins. It is the standard imaging test to diagnose DVT. Comment: Yeah! for POCUS in clinic?
D-dimer: It rules out DVT if it is negative.
Contrast venography: Dye is injected into a large vein in the foot or ankle deep veins in the leg and hip. It is the most accurate test for diagnosing blood clots but it is an invasive procedure, for that reason, this test has been largely replaced by duplex ultrasonography, and it is used only in certain patients.
Magnetic resonance imaging (MRI) and computed tomography (CT) scan. These tests can provide images of veins and clots, but they are not generally used to diagnose DVT.
Treatment of DVT
Anticoagulants: Anticoagulation (commonly referred to as “blood thinners”) is the mainstay of therapy for patients with deep vein thrombosis (DVT). Anticoagulation is indicated for all patients with proximal DVT and select cases of distal DVT. To decide on anticoagulation, we must weigh the benefits versus the risk of bleeding. The primary objective of anticoagulation is the prevention of further thrombosis and of early and late complications. Major early complications of DVT include clot extension, pulmonary embolism (PE), major bleeding (from anticoagulation), and death. Late complications include recurrent clot, post-thrombotic (post phlebitic) syndrome, and chronic thromboembolic pulmonary hypertension.
The most frequently used injectable anticoagulants are: unfractionated heparin (IV), Low molecular weight heparin (LMWH) (SQ), and Fondaparinux (SQ).
Anticoagulants that are taken orally (swallowed) include Warfarin and NOACs: Dabigatran, Rivaroxaban, Apixaban, and Edoxaban. All of the anticoagulants can cause bleeding, so people taking them have to be monitored to prevent unusual bleeding. Monitoring can be with INR (Warfarin) or clinically (NOAC).
Thrombolytics: Thrombolytics (commonly referred to as “clot busters”) work by dissolving the clot. They have a higher risk of causing bleeding compared to the anticoagulants, so they are reserved for severe cases.
Inferior vena cava filter: When anticoagulants cannot be used or don’t work well enough, a filter can be inserted inside the inferior vena cava (a large vein that brings blood back to the heart) to capture or trap an embolus (a clot that is moving through the vein) before it reaches the lungs.
Thrombectomy/Embolectomy: In rare cases, a surgical procedure to remove the clot may be necessary. Thrombectomy involves removal of the clot in a patient with DVT. Embolectomy involves removal of the blockage in the lungs caused by the clot in a patient with PE.
Question number 3: Why is that knowledge important for you and your patients?
In primary practice, we encounter patients with symptoms that may be suspicious for DVT. We must be able to diagnose and treat these patients in a timely manner to prevent further complications. DVT is just below MI and stroke in frequency.
Question number 4: How did you get that knowledge?
I got interested in this topic because of many previous patients I had with this condition. I investigated multiple sources, including, of course, Up to Date, Medscape, but this knowledge has been accumulated over the years of study.
Question number 5: Where did that knowledge come from?
Up to Date, Medscape, Family Practice Notebook, and Epocrates.
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Speaking Medical: Phlegmasia cerulean dolens
by Dr. Valerie Civelli
Phlegmasia cerulea dolens means “painful blue inflammation”. It is an uncommon but severe form of DVT which results from extensive blockage by a thrombus of the major and the collateral veins of an extremity. This phenomenon was discovered by Jonathan Towne a vascular surgeon in Milwaukee, USA.
Phlegmasia cerulea dolens (PCD) is a precursor of frank venous gangrene. It is characterized by severe swelling, cyanosis and blue discoloration.
The next time you look down at a leg that appears like it’s from the blue man group in Las Vegas or appears smurf-like, think of Phlegmasia cerulea dolens.
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Espanish Por Favor: Coágulo
by Dr Valerie Civelli
Coágulo may be a word difficult to pronounce, but it is very important in the context of DVT, MI, or stroke. You may guess what coágulo means by remembering the word anticoagulant. Yes, coágulo means blood clot. “Señor Pérez, usted tiene un coágulo en las piernas” means “Mr Perez, you have a blood clot in your legs”. Coágulo may be used by a patient who also has blood clots in her menstrual period during an episode of menorrhagia or during other excessive bleeding. Now you know the Spanish word of the week: Coágulo.
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For your Sanity
by Drs. Steven Saito, Gina Cha, and Alyssa Der Mugrdechian
What’s black, long and hangs from an a*hole? A stethoscope.
--Patient: Doctor, my son ate a firefly!
--Doctor: Why did he do that?
--Patient: He wanted a light snack.
--Patient: Doctor, doctor, I’ve had a terrible stomachache after eating tamales.
--Doctor: Were they fresh?
--Patient: I don’t know, how can you tell?
--Doctor: How did they look when you removed the corn husk?
--Patient: Were you supposed to remove the corn husk?
Now we conclude our episode number 23 “Blood Clots: DVT”. Dr Gonzalez explained the basics of Deep Venous Thrombosis (DVT) and reminded us that DVT can be easily diagnosed by ultrasound, and that timely treatment prevents acute and chronic complications. Phlegmasia cerulean dolens is just another way to say “painful blue inflammation”, a severe type of DVT that occurs when the MAJOR and COLATERAL veins in a limb are occluded; then, were given the advice by Dr Civelli to recall the word anticoagulant to remember the Spanish word coágulo (blood clot). And we cannot finish this episode without mentioning the name of the first registered COVID-19 vaccine. It’s called Sputnik V. We tried several times to record that name in the intro, but we could not stop laughing. We honestly hope the Sputnik V is a great success regardless of its amusing name.
This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.
If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice.
Our podcast team is Hector Arreaza, Alyssa Der Mugrdechian, Alejandro Gonzalez, Steven Saito, Valerie Civelli, Gina Cha, and Ariana Lundquist. Audio edition: Suraj Amrutia. See you soon!
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References:
University of Southern California - Health Sciences. (2020, July 13). Significantly less addictive opioid may slow progression of osteoarthritis while easing pain. ScienceDaily. Retrieved August 12, 2020 from www.sciencedaily.com/releases/2020/07/200713120014.htm
“Russia registers COVID-19 vaccine, Putin says daughter already inoculated” by Yaron Steinbuch. August 11, 2020, New York Post.
Sterns, Richard H, “Causes of hypotonic hyponatremia in adults”, Up to Date, retrieved on Aug 13, 2020. https://www.uptodate.com/contents/causes-of-hypotonic-hyponatremia-in-adults?search=potomania&source=search_result&selectedTitle=2~2&usage_type=default&display_rank=2