Thromboprophylaxis following s pinal c ord i njury
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Thromboprophylaxis following S pinal C ord I njury. C P Vinod Duke of Cornwall Spinal Treatment Centre, Salisbury. Objectives. Venous Thrombo-Embolism (VTE) Spinal Cord Injury (SCI) Thromboprophylaxis following SCI. Venous Thrombo -Embolism. Blood Flow is essential for Life Arteries

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Thromboprophylaxis following S pinal C ord I njury

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Thromboprophylaxis following Spinal Cord Injury

C P Vinod

Duke of Cornwall Spinal Treatment Centre, Salisbury


Objectives

  • Venous Thrombo-Embolism (VTE)

  • Spinal Cord Injury (SCI)

  • Thromboprophylaxis following SCI


Venous Thrombo-Embolism

  • Blood Flow is essential for Life

    • Arteries

    • Veins

    • Capillaries

  • Clotting of blood is also essential for life!

    • Thrombus – Blood Clot

    • Emboli – dislodged Clot


Venous Thrombo-Embolism (VTE)

  • Pathophysiology

    • Virchow’s Triad


Venous Thrombo-Embolism (VTE)

  • Pathophysiology

    • Virchow’s Triad

      • Haemodynamic Changes

        • Cardiac

          • Artificial Valves

          • Atrial Fibrillation

        • Atherosclerosis

          • Plaques

        • Immobility

          • Bed Rest

          • Paralysis


Venous Thrombo-Embolism (VTE)

  • Pathophysiology

    • Virchow’s Triad

      • Haemodynamic Changes

      • Hypercoagulability

        • Dehydration

        • Infections

        • Malignanacy


Venous Thrombo-Embolism (VTE)

  • Pathophysiology

    • Virchow’s Triad

      • Haemodynamic Changes

      • Hypercoagulability

      • Endothelial Injury

        • Trauma

        • Surgery


Venous Thrombo-Embolism (VTE)

  • Pathophysiology

    • Virchow’s Triad

      • Haemodynamic Changes

      • Hypercoagulability

      • Endothelial Injury


Venous Thrombo-Embolism (VTE)

  • Thrombosis/Emboli in Arteries

    • Stroke

    • Infarct

    • Ischemia

  • Thrombosis/Emboli in Veins (VTE)

    • Deep Vein Thrombosis

    • Pulmonary Embolism


Spinal Cord Injury


SCI - Epidemiology

  • Incidence - 11 to 40 per million

  • Prevalence – 10,000 in UK

  • 50% of SCI seen in 16 – 30 years age group

  • Median age 26 years

  • Traumatic SCI more common in <40 age group

  • Non-traumatic SCI more common in >40 age group


Tetraplegia

C8 and above

C4 and above may be ventilator dependent

Paraplegia

T1 and below

Below L3 may be able to walk

Complete

Incomplete

Syndromes

Central Cord

Brown-Sequard

Anterior Cord

Cauda Equina

Conus Medullaris

SCI Classification


SCI - Mortality/Morbidity

  • 1927 – Harvey Cushing described 80% mortality in WW 1 soldiers with SCI

    • Renal Failure & Pressure Sores

  • Today – In well organised centres 94% survive initial hospitalisation

    • Pneumonia, PE & Septicaemia


  • Thromboprophylaxis in SCI

    • All patients have thromboprohylaxis for at least 12 weeks post spinal cord injury (Unless contraindicated)

      • We use LMWH


    Thromboprophylaxis in SCI

    • Clinical Practice Guidelines (CPG) for Spinal Cord Injury

      • Published by the Consortium for Spinal Cord Medicine


    Thromboprophylaxis in SCI

    • Second Edition Published in Sep 1999

      • First edition 1997


    Thromboprophylaxis in SCI


    Thromboprophylaxis in SCI


    Thromboprophylaxis in SCI

    • Why is it so high following SCI?

      • Failure of Venous muscle pump

      • Transient hypercoagulable state

      • Alteration in Haemostasis

        • Reduced fibrinolytic activity

        • Increased factor VIII activity

        • Dehydration

        • Other injuries


    DVT relative to time Post SCI

    • 80% unprophylaxed patients develop DVT within the first 2weeks

      • Rossi et al 1980; Merli et al 1993

  • 6% incidence at 8 week following stopping of prophylaxis

    • Green et al 1994


  • Thromboprophylaxis in SCI

    • Incidence of PE not influenced by degree or level of SCI

      • Ragnarsson et al 1995

  • Post Thrombotic Syndrome seen in over 60%

    • Chronic oedema, induration, Skin ulceration

      • Monreal et al 1993


  • Mortality due to VTE in SCI

    • Autopsy in Acute SCI deaths -37% due PE

      • Tribe et al 1963

  • Pulmonary Embolism

    • 3rd leading cause of death in Paraplegia

    • 2nd leading cause of death in Incomplete SCI

      • DeVivo and Stover 1995

  • Risk of death due to PE in acute SCI

    • 210 times greater than healthy population

    • Decreases to 8.9 times after 5 years


  • Thromboprophylaxis in SCI

    • VTE in SCI is a silent killer

    • Thromboprophylaxis (Mechanical or/and Pharmacological) if in doubt

    • Contact the nearest Spinal Injuries Centre


    Thromboprophylaxis in SCI

    Thank You


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