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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

Thromboprophylaxis following Spinal Cord Injury

C P Vinod

Duke of Cornwall Spinal Treatment Centre, Salisbury


Objectives
Objectives

  • Venous Thrombo-Embolism (VTE)

  • Spinal Cord Injury (SCI)

  • Thromboprophylaxis following SCI


Venous thrombo embolism
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
Venous Thrombo-Embolism (VTE)

  • Pathophysiology

    • Virchow’s Triad


Venous thrombo embolism vte1
Venous Thrombo-Embolism (VTE)

  • Pathophysiology

    • Virchow’s Triad

      • Haemodynamic Changes

        • Cardiac

          • Artificial Valves

          • Atrial Fibrillation

        • Atherosclerosis

          • Plaques

        • Immobility

          • Bed Rest

          • Paralysis


Venous thrombo embolism vte2
Venous Thrombo-Embolism (VTE)

  • Pathophysiology

    • Virchow’s Triad

      • Haemodynamic Changes

      • Hypercoagulability

        • Dehydration

        • Infections

        • Malignanacy


Venous thrombo embolism vte3
Venous Thrombo-Embolism (VTE)

  • Pathophysiology

    • Virchow’s Triad

      • Haemodynamic Changes

      • Hypercoagulability

      • Endothelial Injury

        • Trauma

        • Surgery


Venous thrombo embolism vte4
Venous Thrombo-Embolism (VTE)

  • Pathophysiology

    • Virchow’s Triad

      • Haemodynamic Changes

      • Hypercoagulability

      • Endothelial Injury


Venous thrombo embolism vte5
Venous Thrombo-Embolism (VTE)

  • Thrombosis/Emboli in Arteries

    • Stroke

    • Infarct

    • Ischemia

  • Thrombosis/Emboli in Veins (VTE)

    • Deep Vein Thrombosis

    • Pulmonary Embolism



Sci epidemiology
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


Sci classification

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
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
    Thromboprophylaxis in SCI

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

      • We use LMWH


    Thromboprophylaxis in sci1
    Thromboprophylaxis in SCI

    • Clinical Practice Guidelines (CPG) for Spinal Cord Injury

      • Published by the Consortium for Spinal Cord Medicine


    Thromboprophylaxis in sci2
    Thromboprophylaxis in SCI

    • Second Edition Published in Sep 1999

      • First edition 1997




    Thromboprophylaxis in sci5
    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
    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 sci6
    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
    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 sci7
    Thromboprophylaxis in SCI

    • VTE in SCI is a silent killer

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

    • Contact the nearest Spinal Injuries Centre



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