bananapeppers Posted July 23, 2013 Share Posted July 23, 2013 i tried researching for this answer but couldn't find it. my preceptor asked if it was necessary to do ultrasounds or ct on a patient before discontinuing their treatment for PE. anyone have any answers to this? thanks!! Link to comment Share on other sites More sharing options...
rcdavis Posted July 23, 2013 Share Posted July 23, 2013 Without directly answering the question, may I suggest a review of the indications for, and proposed length of treatment of DVDs. Particularly review what a DVT is, its pathogenicity is, and the purpose of anticoagulation, whether that ge heparin, Coumadin, lmwh or factor Xa inhibitor.. What is the purpose of treatment? What else should be being done while treatment is being started? What is the basic rational of treatment? How long do we treat? Why that long? What happens to The clot? Therein lays the answer to your preceptor's probing question.. Which is a great one designed to help you understand DVT and the issue of hypercoagulabilty more completely Good hunting! Link to comment Share on other sites More sharing options...
bananapeppers Posted July 25, 2013 Author Share Posted July 25, 2013 Without directly answering the question, may I suggest a review of the indications for, and proposed length of treatment of DVDs. Particularly review what a DVT is, its pathogenicity is, and the purpose of anticoagulation, whether that ge heparin, Coumadin, lmwh or factor Xa inhibitor.. What is the purpose of treatment? What else should be being done while treatment is being started? What is the basic rational of treatment? How long do we treat? Why that long? What happens to The clot? Therein lays the answer to your preceptor's probing question.. Which is a great one designed to help you understand DVT and the issue of hypercoagulabilty more completely Good hunting! so after spending some time reading up on PE, mainstay tx is usually LMWH in the hospital and then add warfarin with INR levels between 2.0-3.0. usually patients who have had previous DVTS/PEs would stay on warfarin for life. patients who had their first dvt/pe would be on 3-6 months. so how would we know when to discontinue the patient off warfarin? my answer: we would measure d-dimer again to see if it's elevated, if it's elevated, continue warfarin and measure using leg u/s and/or ct. it's not elevated, we can discontinue warfarin, thus we would not need to do an u/s or ct scan again. is this correct? Link to comment Share on other sites More sharing options...
rcdavis Posted July 25, 2013 Share Posted July 25, 2013 Pretty much. Does it make a difference WHY there was a clot in the first place? Link to comment Share on other sites More sharing options...
cbrsmurf Posted July 26, 2013 Share Posted July 26, 2013 pertinent study http://www.ncbi.nlm.nih.gov/pubmed/17065639 also don't forget the new factor Xa inhibitors like rivaroxaban, dabigatran (and another one I can't remember the name of right now). These will likely/gradually replace warfarin (and possibly lmwh) for anticoag. hint: rcdavis' last question is important when deciding your management. Link to comment Share on other sites More sharing options...
bananapeppers Posted July 26, 2013 Author Share Posted July 26, 2013 Pretty much. Does it make a difference WHY there was a lot in the first place? you're asking the causes of dvt, right? i think the most common is venous stasis, post/op surgery, pregnancy, malignancy... Link to comment Share on other sites More sharing options...
rcdavis Posted July 26, 2013 Share Posted July 26, 2013 Do you think there is or should be a difference between the approach to a stasis clot ( trauma, immobilization), and an innate hypercoagulable state clot ( malignancy, protein c, etc)? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 26, 2013 Moderator Share Posted July 26, 2013 Do you think there is or should be a difference between the approach to a stasis clot ( trauma, immobilization), and an innate hypercoagulable state clot ( malignancy, protein c, etc)? anyone who says you aren't ready to teach is just wrong. I don't care what your degree is. Talk to my friend Knappy. maybe he can set you on the path to getting credentialed as an instructor for his program. Link to comment Share on other sites More sharing options...
bradtPA Posted July 26, 2013 Share Posted July 26, 2013 anyone who says you aren't ready to teach is just wrong. I don't care what your degree is. Talk to my friend Knappy. maybe he can set you on the path to getting credentialed as an instructor for his program. I know he was teaching from his past military days. We ex-NCOs were constantly teaching. And I would let him teach me anytime! Link to comment Share on other sites More sharing options...
ajnelson Posted July 26, 2013 Share Posted July 26, 2013 anyone who says you aren't ready to teach is just wrong. I don't care what your degree is. Talk to my friend Knappy. maybe he can set you on the path to getting credentialed as an instructor for his program. I learn the most (emergency med wise, anyways) from the two of you! And it reminds me that I still have a long way to go to ever match the amount of knowledge that you guys have! You guys are great role models for us youngin' PAs! And great way at leading the OP to the answer without just handing it to him/her. I'm sure this is something that will stick with them for their career now! Link to comment Share on other sites More sharing options...
LIPPER Posted July 27, 2013 Share Posted July 27, 2013 Don't think all the factor Xa's are indicated for DVT yet...hopefully soon. Link to comment Share on other sites More sharing options...
FBIDoc Posted August 1, 2013 Share Posted August 1, 2013 Not to hijack the thread but as long as there are no reversal agents for the new-fangled, devastating-head bleed-causing anticoagulants, I see no end to the LMWH and Coumadin usage... also, one of the replies above indicated using d-dimer as a marker for therapy discontinuation...what other conditions might a patient have that can elevate d-dimer in the absence of DVT/PE? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 1, 2013 Moderator Share Posted August 1, 2013 Not to hijack the thread but as long as there are no reversal agents for the new-fangled, devastating-head bleed-causing anticoagulants, I see no end to the LMWH and Coumadin usage... also, one of the replies above indicated using d-dimer as a marker for therapy discontinuation...what other conditions might a patient have that can elevate d-dimer in the absence of DVT/PE? also d-dimer can be low in the presence of a large clot which has been present for an extended period of time so it really is only helpful initially in the natural course of a dvt or PE. we had a great case a few years ago of a guy with 2 weeks of chest pain with large b/l PEs and a nl d-dimer because of this phenomenon. he actually went through a full acs workup with 2 sets of enzymes, passed a standard treadmill, etc and his only finding picked up by an astute clinician was a persistent tachycardia even when asleep( like 105 or something). Link to comment Share on other sites More sharing options...
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