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Hi. Um, so can co someone confirm in the chat if they can see and hear us properly? Mhm. Ok. So, hello everyone. My name is Dia and I'm the vice president of Grad Scape. Thank you all for joining today's talk. And I would like to hand over to Dr Kevin De Souza. Hello. Um, good evening everyone. I'm Kevin. I am a clinical fellow at Bedford Hospital. Um I'm pleased to give you this talk today on Pe DVT and VT Prophylaxis. Um Please feel free to stop me at any point if you feel like I'm fast or if you have any questions. Um, and I'm, I'm more than happy to answer any questions. Um We'll go through PE DVT and BT and a bit of BT prophylaxis towards the end. Um A bit of M CQ and we'll finish off with uh my clinical case, like I said, feel free to stop me at any point if you need to ask me any questions or if I'm not clear about anything. Um So we'll make a start. Can any everyone see the presentation? Just, just say a yes and we'll keep going just to make sure sweet. Ok, so um this talk is gonna be I'll start off with the, what I tried. Um We'll go in depth about a pe and a DVT um a bit about BT prophylaxis, uh how it is important being a doctor in the UK. Um anywhere as a matter of fact, and we'll finish off with um some M CQ and some clinical scenario. Um feel free to um speak to the microphone or put your message on the chat box for any questions I'll ask in between um or game cameras on up to you and no pressure. Um We'll start off with what was tried. So this is something that we should just know at the back of our heads. Um It's a theory suggests about um a German um back in 18 fifties, it's um the fact is that increased chances for someone to develop AAA thrombotic event or thrombus in their body. Um So it's the first thing is that hypercoagulable state is when your body is prone to be um in a state where the blood is more, more likely to clot than not. Um such as when you have a cancer. Um when you take over the counter pills, um sepsis, um post surgery, post surgery can be hypercoagulable. And second is endothelial injury is when you have, like I said, surgery where they, there's a lot of breaking down of blood vessels, et cetera. They, they put you in a, in a state where you are also prone to get thrombus, the loss is venous stasis. Um This is when there's a obstruction to the normal flow of blood. Um This is just a summary. So putting all these three together, um if you have any of these risk factors, you should always think about um that the patient will be having um a risk of having um a VT event. So you wanna um plan your treatment, um given that this is a risk, so you want to maybe anticoagulate uh as a prophylaxis. Ok. So we'll start off with pulmonary embolism. Um As most of, you know, I believe, um pulmon embolism is, is a life threatening condition where one or more embolus emboli embolus, um normally arising from somewhere else in the body, um, dislodges itself and comes in um sticks in one of the arteries and blocks the rest of the flow going forward. Um This is a life threatening situation, obviously depending on the extent of the pe. Um And in general, this is how we divide it, um the patient basis. So it can be divided as provoked and unprovoked, um, provoked is when you have a risk factor that can, that, that can possibly be causing the pe. So if someone had a recent surgery, um some trauma recently, history of DVTs coming out of pregnancy or in pregnancy using over the counter pills, these are all are like major risk factors that, you know, can. Um, so when you see a patient, you know, this is one of the backgrounds, you know, this might be one of the reasons they are having this pe or they are suspecting a pe but someone else who has no background whatsoever, um, that we know of to date, uh, and they develop a pe that's called an unprovoked. Um, um, the treatment is the same, um, initially but for unprovoked PPE S, we normally have to investigate further what possibly caused the pe. So there's just a general division of, of patients that come in next. We move into the risk factors. Uh, like you mentioned before, the, it, it's quite repetitive for DVTs and P ES. The risk factors almost coincide. Um If you have a DVT, there's a chance, I mean, there's an inevitable chance that you can have, um, a pe it can dislodge from one of the deep veins to your lungs, obviously, because the veins go up to your heart and then eventually to the lungs to the pulmonary arteries. So anything in that route eventually will lead to your lungs. Um, so that's one of the risk factors, recent surgery. Um, it's, it's, um, highly important you anticoagulate these patients for, uh, at least 2 to 4 weeks after surgery to prevent, um, any post surgical thrombosis or pe um, immobility, someone who is gonna be at hospital for at least a few days, um, they will be immobile, they're gonna be in their beds. This is another risk, uh, venous stasis. This is one of the causes immobility and then eventually forms a clot and then like which, which can cause a DVT first and eventually go to the lungs. Previous history of VT es cancers, cancers is a big risk, um, for someone, um, to develop a pe as well. Um, VT for that factor for that factor matter. Um, other risk factors if you're pregnant, um, hormonal therapy like CPS or H RT S. And um, another good um, risk factor that you can get from history from the patient is long travel, uh, smoking, obese, obviously, by clinical cli uh clinically, you can see the patient and any previous medical conditions. So long travel is um a good tip when you take history from a patient, make sure you, you rule out any long travels in the last two weeks. Um, long haul, longer flights, which are six hours, seven hours where they just sat down even long drives sometimes where you just sat down, you don't take a break. You're, you're putting yourself um at risk for venous stasis and eventually a thrombus come to symptoms. Um, pe is, is, is, is uh life threatening. Um, but they can present in different, different ways, but the most common symptoms that you see, um, are dyspnea, um where they have sudden onset, it can be gradual, but it's not longstanding, it's not like it's been two months or 2.5 months where it's gradually getting worse. That's more of a heart failure picture. Uh, but when you have someone with acute, um, incidence or shortness of breath, unable to, you know, um, breathe out, they normally used to. Um, and they have some kind of chest pain as well. Um, p chest pain when you take a deep breath in, um, hemoptysis. Um, this is so based on how many patients I've seen a lot of patients that come in with pe um hemoptysis is not really common among the patients I've seen. Um but if this is one of the presenting um complaints, um it is um a, a crucial factor like, you know, we're heading towards that pe side um tachypnea, high, high respiratory rate, um DVT symptoms if they have a, a concomitant DVT as well. Um chest pain cough and this cough is not like your normal infection cough where it's gonna be a sputum. Um You listen to the chest, it's all crackly and stuff. The chest can be clear when you listen to the chest. Um X ray can be clear as well, but they have a cough, they bring up some blood with it if, if, if they do, but it's, it's a different kind of cough. Um The main thing you need to rule out. Uh main thing you need to see is the shortness of breath, they're always gonna be desaturating. They won't be maintaining their SATS. So they'll be saturating. If someone's not CO PD, they'll be saturating 9390 to 91 and you have to put them on nasal cannula um to, you know, to help their saturations go above 94 other signs um elevated J BP is when you see a raised um pressure in one of the main veins in your neck. Obviously, with experience, you can, you can, you can um guide yourself on how to see a elevated JVP, but it's not something that um you go and look at straight away. But if you can see that and it's clear that it's uh it's a JVP, that's, it's a raised JVP. It's a good indication that, you know, this, this could be um some element of pulmonary edema, maybe if not pe causing right heart strain as well eventually. Uh and other symptoms, other signs can have a fever. Um You can have a split second heart sound, which is uh also not that common that I've seen uh that I've heard, but I it does happen um hypotension. So hypotension is a, is, is a really important um symptom. Uh a sign that we have to keep an eye out for when they go really when the systolic pressure goes below 90 they're in shock, we have to consider whether we need to thromb this patient. Obviously, if indicated, we have to, we have to look at risks as a benefit. Um And we have to go into the thrombo like the thrombolysis route. Um And yeah, hypoxia, obviously, because of the shortness of breath, you will have hypoxia as well. And tachycardia, these are the physiological response of your body given that your body is not aerating. Well, because of the thrombus um by dyspnea, um chest pain and hemoptysis, hypoxia. They on nasal cannula, you go see the patient, he's on nasal cannula, not saturating enough and you see tachypneic, you should always think, OK, this, this, we have to rule out our pe because this is, these are cardinal signs. So that's one those are the symptoms um um everyone OK to hear to am I going too quick? I just wanna double check just uh if I am, please let me know. Um So those are your initial bits and then eventually you go into diagnosis. So, as a clinician, as a doctor, um it's your um your gut feeling what you feel at that time, you can make um a differential diagnosis. You don't diagnose the patient straight away uh with a pe without doing a um a, a diagnostic test that confirms a pe. So you wanna put your diagnosis as to rule out pe and you carry out the different tests. Um So E CG uh you can have ranges of EC GS, you can have sinus tachycardia. Um But there's one very specific uh pattern that you see in pe obviously cause pe um when it f depending on the size. Um it can cause right heart strain cause um the, the right ventricle pumps the blood through the pulmonary arteries. And when there's a blockage, there's a backflow eventually causes right heart strain. And you see these changes on the ECG in the pattern of S one Q three T three. Um It's basically a um a more prominent s in, in the lead one, you see a more prominent Q in lead three and at wave inversion in lead three as well. So when you see these three things now, you know, like you're almost there, like you, you've got enough, enough things backing you up that this is a pe for sure. Obviously, if you see ST elevations and whatnot in, in, in the pre recorded leads and you also have to rule out an M I. So you send off three diers and trop. So E CG is one of the first things anyone that comes in with chest pain, they do an ECG in in A&E anyway is why they try. And so you should have an ECG ready when, when you see the patient, you do a chest X ray as well. Rule out pneumothorax, pneumonia causing it. Uh and mind you, these chest X rays can be clear. Um And then it's even more definite that it's not a pneumonia, it could be something else. Uh Bloods, you have some normal bloods anyways FP CS using these um liver function, bone profile. Uh But the one thing you should consider with someone with chest pain, with ECG changes is a drop and ad dimer. So D dimer is, is, is not um when it's negative, when DD is negative. So the normal value for D dimer is 0 to 250 D dimer is basically telling you that there are, there are clot breaking down in your body. This is a breakdown product of a clot. Um So when your D dimer is high, it does not fully mean that it is a pe. Um but it does not rule out a pe because D dimer can be raised in multiple um situations, cancer infections. Um Many other situations, not just um a pe, but it also can be increased in a pe. But when it's negative, when it's below 250 or n almost negligible, you're almost almost um almost there, almost sure that it, it's not a pe cos if a DD is negative, there's no clot formation happening in your body. This could be something else causing these symptoms. Um So you want to send ad dimer for sure. You want to send a DD dimer for anyone that, that you wanna do a lot of DVT or APRA pe, you have to send AD Dier because you can use it as a justification for your C TPA later on. So imagine the level comes back, comes back high. Um You have to go for the, for a C TPA. Um There's a few scoring systems that you can use to diagnose. I mean, to um justify your, your case to the radiologist when you wanna tell them. Ok, I've got this patient, he's coming with chest pain, he's got dimer, he's hypoxic and you do a V score. So someone who's got a vel score higher than 4.5. Um To be honest, it, it ranges, they can have a well score from three to whatever is the highest. Um If it's high, it is high, the probability it's a pe um obviously, if it's zero, then um you can't justify your case. But if you're just, if you, if you're quiring a pe by then I think your score will always be 4.5 or above because they always be, that's your first. Um That's your first diagnosis that you're thinking yet. So he's gonna have three points already. So, um that's a well score and pesi score is someone who's already have, who's already been diagnosed with a pe, what's their mortality rate in 30 days? So this is after you diagnose the pe. So, wells score is prediagnosis, pesce is after. Um And obviously, once you have all these um no point of faffing around, you have to book a C TPA. Obviously, you are running by registrar, someone see you in the, in, in the, in the, in the ward or if you're in A&E your consultant during the day or during the night and request a C TPA call the radiologist straight away. Explain the situation. Tell him this is the situation. Well, score seven D dima rays, we need a C TPA as soon as possible. Um Make sure that the kidney function of this patient is, is ok because people with uh because it's contrast, enhanced people with CKD um contrast don't work really well with them. They can go into contrast nephropathy, given the kidneys already, you know, shutting down. So then you might want to consider a VT scan. Um but um it, it, it depends on, on, on the seniors. Sometimes they decide to go for it hydrate the patient before and after. So, uh the gold standard to diagnose is a CT PA is where they put a contrast into your veins and eventually they do a scan. So this is a C TPA that I've just, just included a um a snapshot. So you can see the, can you guys see the gray um gray area and the really white area? The differ is it is it well differentiated in, in the slide? Just um yes, if that, if, if, if you, if you can see it um that that little um line of um grayness that is, that is the embolism that is um filling defect, that's how they normally require, report it. The radiologist as a filling defect in one of the arteries. Obviously, this is more of like, um, really up. So it's where the, where the arteries bifurcate. So it's called a s somewhat of a saddle pe, saddle pe is when, um, it's literally at the bifurcation. So you're obstructing flow to both the lungs and this is a high risk for the patient. They are at risk to go into hypertension shock and then eventually they will arrest. So you have to consider whether they need to be thrombosed or not. So, so this is um ideally how you go about someone with C TPI, someone with pe um obviously, throughout um throughout this whole process, you will have senior support, you can run anything by them. Um And then eventually you have to get a C TPA done. So once you've diagnosed your patient with a pe um can anyone tell me what's the first line treatment? Um before I go to the next slide, what would you want to start the patient on anyone on the chat or anyone wants to get the microphone on? OK, fine. Uh We, we, we no normally start them on anticoagulation. Um So yeah, that's good. Yeah, that's, that's what we use in my hospital, low molecular heparin. Uh We, this is just a guideline from um nice. Um It's, it's just how you, you can have a look at it later on. It's just um a flow chart of how you do exactly what, how I explained it just in a flow chart manner. So, yeah, so you start off with anticoagulation. Um You can do fond theox is mostly mainly used in another situ another medical condition like M I, they normally use Fondaparinux but low molecular weight Heparin, which is Tenzin. Um You can start them on Warfarin, which is not really ideally used in OXY. Yeah. Um In my hospital generally we start them with sub Tenzin. Um And then eventually we, we, before discharge, we, we switched them to oral DUA. So these are the um new oral anticoagulants or the um DUA, whatever they're called. Um And we normally send them either on Apixaban or Adoxa. So you have to load them. Um If you start them straight away, you load them for seven days and then start them on a maintenance therapy. But if they've already been receiving tear and then you just continue with the BD dose or the once a day dose for Edoxaban, um you start the anticoagulation unless it's absolutely contraindicated that this patient is having no bleeders by at the same time, then you got to outweigh risks and benefits and see what's, what's going to kill the patient first and what's going to save the patient first. And then you make a decision accordingly. To be honest, when you have a situation where you're bleeding and you have a pe um like ad IC picture, it's really hard um to make a decision, but it has to be done. Um a prognosis might be poor for the patient, but it has to be done. Uh, if it's a, if it's, um, contraindicated, then you can start, um, thinking about IVC filters. Obviously, catheter guided patient has to be sedated into surgery where they put a filter in one of your veins, one of your deep veins. So the clot, if there's a clot, it doesn't go all the way up to the lungs. Um, pretty much basically like a filter like a sieve. So it doesn't let the filter, it doesn't let the uh, clots go up. This can be done elective as well. Um And thrombolysis, thro thrombo thrombolytic agents are used, like I mentioned before when you have someone that's got pe high risk pe like the one I showed you before, which is a saddle P ea massive pe and the patient is hypotensive and he's not picking up his sats. This is when you, you have to consider, um, pardon me, you have to consider uh thrombolysis and this is a senior mediated decision. They have to outweigh risk and be risk versus benefit. There's a whole performer on it. Um And they have to go through each one of them and make a decision at the end if, if they wanna, if they wanna thromb the patient, there was a patient the other day that had, um, possible, I mean, had a pe because they ruled out the, the, the um, t um uh hes and TS for a patient who arrested in the A&E and I think eventually the only thing remaining was an embolus and they thromb him while he was in the waiting room. Um, so that's how, that's how it is. The decisions has to be made, uh, like within, within a span of time or the patient is not gonna survive. So, um, yeah, when it gets a thrombolysis route, you have to really consider whether it's, it's worth it or not. So, and the last thing is surgery, I personally, I have not come across um, anyone that's had this done to them, but theoretically, this was also possible um where they do an open pulmonary embolectomy by the catheter guided embolus removal. But initially you start them on, on, on anticoagulation most of the time. Um and Thrombo if they're, if they're in hypertensive shock, um and their body is shutting down. So that's, that's, um, that's an overview on PS. Um Please let me know if there's any questions or are you, are you guys happy for me to uh move on to DVT? Just say yes or you're OK. And then we'll go forward. Can you guys hear me? Um Yes, if it's a yes, sweet. Ok. That's fine. Yes, sir. Go ahead. Ok, so we'll go next. Um going forward, we go to DVTs. These are, um, this, this just, this happens before pe if you catch it at a DVT stage, it's good for you, um, good for the patient actually. Um, and for you as a clinician. Um, so this is a formation of a clot in a deep vein normally in the legs. However, it can happen, um, anywhere in the body where there's, uh, any of these watches, tried playing around. Um, I've never seen anyone with a DVT and I've never actually come across with anyone with a DVT in the upper limbs, although we've suspect suspected it, but I've never had anyone that had a pe in the upper limb, the lower limb. Really. I've had many patients that have that, that be, that have been diagnosed with a DVT. Um, although it can happen anywhere in your body, um, in the brain, liver kidneys, anywhere where there's an obstruction, clot can form and then dislodge and eventually go into your lungs. So it can happen anywhere. But most likely most common is within your deep veins of your leg. Risk factors. Again, it's, uh, they coincide, it's pretty much the same, both of them. Um If you have a history of DVT cancer, um, elder, elder patients, elderly patients, um, obese, uh varicose veins which are already obstructing is already meeting your word. Just try obstructing flow endothelial injury. Um If you have family history of any kind of, um, coagulation disorders, uh laden five factor five laden, uh thrombophilia, all these, um, these people come in with recurrent DVTs, people who have coagulation disorders. Uh, they come in with recurrent DVTs, you start them on a doac, they come back with a DVT again. You start them on Warfarin, they come back again. So it's all about, um it's all about tackling what, what we can give them eventually to keep them stable and DVT free for a longer time. Um But every other person who has recurrent DVTs, you have to investigate, if they don't have a, a previous history of any kind of disorder, you have to investigate what's causing this recurrent DVT. Um So those are intrinsic and temporary, same as the same as um P ES. So um recent surgery, hospitalization where you, where you're immobile for a while, you don't move a lot. Um Trauma, chemotherapy, uh hormone replacement dehydration, dehydration makes your, makes your uh it just makes more sense. I mean, there's less water in your body blood becomes more thick chances for a clot. Um There, there was one patient who who was diagnosed with um um some, some primary source of cancer with, with um me to his brain. So he was a, he was a repat from another hospital. He was, he was admitted for some, some sort of infection. So he was, he was in the hospital for a few days um uh for almost a week and um he was not prescribed VT prophylaxis when he was in. Um So he was OK for like six days and on the seventh day, he developed some kind of chest pain overnight. Uh, we didn't look into it that, I mean, the doctors, I didn't look into it that much next morning. He desaturated. He had, uh, he was requiring oxygen. Um, so we had to go through his medical profile to see what he's on and what, what, what, what caused it. Obviously he's got cancer. So it, it, we, we almost, we without thinking, we, we thought that he must have been anticoagulated. Um going through his medical history, he wasn't anticoagulated. Um He was in the hospital for seven days without anticoagulation, prophylactic, um not therapeutic. And now the only thing we have to do is rule out a DVT or a PE in this case, a pe because he was hypoxic. Um So we just booked a CTPA straight away and he had a pe. So, um seven days for someone who has got cancer is very long. Um And there's a high chance that it can develop a pe. So, uh we want to be really careful with these, these patients that meet, that have risk factors and you wanna make sure they have prophylaxis uh prescribed, we, we'll get into prophylaxis in a bit. So, um obviously, the last thing, complications of A DVT eventually is gonna go all the way up and then you are gonna end up with a pe. Um Another thing that can happen is you can have this uh post thrombotic syndrome as well because the clots obstructing your flow of blood distally from there. Um It can cause hypertension of the veins, uh downwards, uh limb pain, swelling, venous ulcers, um change in skin color, venous gangrene. Um All these are symptoms that is post the thrombus and you will see venous changes. Um uh very commonly in patients with DVT that have been there for a while. Um But yeah, you want to catch it at a DVT stage So you can start treating it before it. Uh dislodges and go into, into the lung. Uh reduce chances for it to go to the lung after you start anticoagulation. Um Just to, just to clarify, anticoagulation is not something that's gonna break the clot. Um It just prevents any further clot formation. So if you have a clot of this size, it does, it won't become bigger. Um And in the meanwhile, your body will try breaking down the clot that's already formed. Uh It might take months to two years for it to eventually fully subside. Um On the other hand, thrombolysis is when you actually break down the clot. So it's called clot busters. Um It's I have a flow of, of the coagulation cascade and I'll, I'll, I'll explain to you um what works well. So just, just a disclaimer. So, anticoagulation is not to break the break the clot. It's just to prevent any further clot formation. But uh thrombolysis is where you actually break the clot. It's, you are breaking the, the blood clot and then any clot in your body can break, can break and start bleed. So that's why the, those are the risk. So someone's got some kind of cavernous hemangioma in their brain, you give them thrombolysis, they're gonna bleed from the brain as well. So you're gonna have two issues at once. So that's where it gets a bit tricky. So, but those, I mean, you normally have to escalate. You don't, you don't, you don't call that shot of thrombolysis as a junior doctor, you always have to get someone, see you involved. So by, I mean, like senior reg or consultant. So yeah, signs of DVT. So this is a bit different. So people with pe might not have these symptoms, um unless they have both at the same time. So it's normally unilateral. Uh if it's bilateral and if it's um amas and there's no redness, you have to rule out heart failure cause heart failure is normally bilateral. Pitting edema can be up to the thighs. Uh But if it's bilateral, you have to rule out heart failure as well, uh which can also cause shortness of breath. So, um some symptoms can coincide. Uh but with the DVT, you can have a single one sided um um cough pain, um on walking and this is something that they've, they've realized recently in the past 11 week. Um, calf swelling, warm to touch, um, tender when you press it it's always tender. So you have to make it part of your normal clinical um, clocking when you clock a patient in, you always want to see if their calves are soft and non tender. So at least when you saw the patient and they didn't have a DVT cos if in it going forward, if this patient did eventually have a DVT and it was missed, at least you have backing up that you've seen the patient at that point, you saw the causes and it was soft and nontender. So now a few other things that you can do is obviously measure the diameter if you have. Um if you have something to help you measure it, if it's more than three centimeters compared to the other, other cuff, um you have to rule out a DVT. Um This is also something backing you up if you wanna do a scan. Uh but you don't do a CTP for someone with DVT. You normally do an ultrasound, which will, will go into it in, in, in a bit. Um The same time you can have edema uh of that leg, maybe of the full leg sometimes, but normally downwards from the, from the clot um location. Um And you can see collateral veins forming um to compensate. So, um these are, these are really, really uh specific symptoms for DVT, obviously, people with cellulitis. Um um it might be a bit confusing, some people might have cellulitis with a similar picture where they have uh redness, um tenderness and all that, but the bloods come back with high infection markers. So you treat us both until you rule out uh A DVT. So you give them antibiotics and you give them anticoagulation until you get an ultrasound scan. Um So these are the signs going forward diagnosis. Again. The DVT is more for clinical diagnosis, obviously. Um Given that you can see why it is happening with the leg. You, you know, if it's a DVT or not, if you see someone with clear uh nice coughs bilaterally, you know, it's not a DVT, but someone's having unilateral uh symptoms like we explained before uh signs and symptoms. You want to rule out a DVT again. Um You send ad dimer, um it can be raised if it's raised, it does not um rule in the DVT doesn't, neither does rule out it, it gives you a, a pro probability that it can, a DVT can be possible, but if it's negative, it's unlikely. So DDA, if it's negative, it's really unlikely for PE and DVT. So that's probably one thing you can take away. Um If D DAA is high, it does not mean it's confirmed, it's just um helping you back your back your diagnosis. That's it again, vs score doesn't, does, it's similar to the PE but there's a specific wells score for DV DVTs. Um Again, you wanna use that to back your um back your diagnosis, you do a wells score as well. Um But eventually all these patients will need the ultrasound Doppler. Um So this is no, I normally I actually put a slide that normally move uh that is in motion, but this is not moving spot if you see here. Um This is a Doppler scan. When they do the Doppler, you will see color filling here and here, but this will be empty, There will be no color filling here. That means there's no blood flowing through that area. It's just blocked and on a long axis. Um Basically the, the ultrasonographer normally do this, but this is just for your information. When you see a scan in the future, this is a bit, this is a clot sitting in one of the veins. Um Can everyone see that um or is it moving for you guys? Uh it's not moving for me. So I'm just gonna locate it. So this is a clot in one of the veins and these are color fillings. So uh just a small um information, a small tape as well. Blue and red does not mean artery and veins. Um blue means that blood is going away from the transducer and red means blood is coming towards the transducer. So this is the veins, you can't have arterial blood. So it basically tells you the the direction of flow of blood. So in this, in this situation, there is flow here, there's a bit of flow here. But if you actually saw the picture in, in in real time, there will be flow all the way here and all the way here, blue and red, but there'll be no flow going through this area. So that's when you know that you know, you have a fat thrombus sitting in one of your veins. So this is probably this is one of the veins in your, in your, in one of the deep veins in your lower limbs. And yeah. So the this is more of um your, your diagnostic tools that you use for, for DVTs. Um And obviously eventually you have to get Doppler. So next is treatment um in my hospital, normally we start them on treatment for DVTs with anticoagulation again, uh with a DOAC um and we get them to go home if they are able to or keep them as an inpatient until they can get an ultrasound scan of the lower limbs. Um If it's confirmed a DVT, we can continue the anticoagulation for 3 to 6 months and we reassess um if it's negative, we stop the anticoagulation. But if we do discharge these patients, we have to make sure that we let them know they are on a blood thinner and if they do have a fall or if they do have any, any kind of injury or any kind of trauma, um there can be a severe risk of bleeding. So we have to let them know before they leave if they're inpatient, um, still let them know, but they will not, I mean, at least they will be in the hospital vicinity. So we can, we can, we can, you know, treat them all the and yeah, these are just other things that you can do. If you don't, if you do not want to anticoagulate patients, you can do compression stockings. Uh, but you don't want to give it to people that have, um, um, severe, like, um, uh, redness, severe pain. Um, if it's maybe no clinical signs of DVT, but the D I measure race and you want to rule out a DVT, then maybe you can give them a compression stockings. Um, I would suggest maybe not, maybe just start them on anticoagulation and then, uh, book an ultrasound for the next morning and then, you know, for sure if it's a DVT or not. Um, and then if it's unprovoked, like a pe you want to consider other, other causes as in what's causing the DVT. Um, and history is one thing that you need to get, um, you need to, um, focus on cause you want to make sure you, you find any, anything possible that can be a risk factor. Uh, long haul flights, maybe they had a surgery 22 months ago, but they're not letting you know, they mean the conversation never came up. You have to ask them any recent surgeries or anything like that? So, um history, history is really important for these kind of um for P ES and DVTs. So, um, yeah, so that's, uh, that's, that's all about, uh, DVTs and P ES. Um, is, is, is, is that clear to you guys? And can we move on to BT prophylaxis? Are there any questions that you have? Anything that was not clear? Um, anything that you want me to repeat or anything like that? I'm more than happy to give you. Give you like 30 seconds. Sweet. Got thumbs up. Ok, thanks. That's good. I don't think anyone else is gonna. Ok, that's fine. So we'll go to the next, um, if you give me a minute, I'll just switch on, on my light. Ok. Um, so we go forward to VT Prophylaxis. So this, this is really important for, for doctors working in the UK. Um, you, anyone that you clock in, um, um, as a junior doctor or as a, anyone that you clock in, you wanna assess if they need to be, this is if they're not having a PE or DVT, that's when you give them VT. Um, you give them treatment, do Tenzin or anticoagulation regardless. But if someone is coming with pneumonia or something else, um, not a thrombus or not a VT E, you wanna make sure that you wanna assess the risk for them to develop with a DVT or a VT or a PE while they are in the hospital. So different hospitals have a different performer in my hospital. We normally have a checklist. Um It tells you contraindications and um risk for VTE. So uh we fill in why we think are the risks we fill in. Why we think are the contraindications and eventually the computer will give us um a sign saying this patient is at risk or not at risk. So if it's green, not at risk, if it's red at risk. So then you decide whether you want to anticoagulate the patient. It is it is your decision at the end of the day as a doctor, as a clinician, it's your decision um whether you want to anticoagulate someone or not. Um But it's VT E prophylax, VT E is generally VT prophylaxis is generally um you giving something to the patient to prevent um any, any event uh during the admission includes both PE and DVTs obviously. Um and hospital acquired VT E. This is where some of us can get stuck. Uh So if someone comes in and you clog the patient and um you don't prescribe VT E, you forgot or you don't. Yeah, if you don't prescribe, but you've mentioned that you do not want to give the patient VT E. That's fine. That's your decision. You, you can maybe you can back yourself saying the patient was fit and mobile prior. He was only here for two days. I didn't want to give him a VT E prophylaxis. Um But if you do not um document VT risk and you do not um do the whole performer and the patient is admitted for four days. They were, they were fine. They eventually went home and they came back within 90 days having a PE or DVT, they go back to the patient's records and see recent admissions. And if the VT risk was not, um was not uh recorded by the clocking doctor last scene, the last uh admission, um it will come down as a missed uh VT E. So we could have prevented that. So this is something for you to be aware of. Um it's called, it's called Hospital Coed VT E. So within 90 days, um we have a VT coordinator in our hospital who normally takes care of these things and she's on our case every day. You have to do VT E assessment. You have to do a VT assessment because it is important. Uh like I said, the cancer patient who came for seven days, he's already in, in, in, in loads of trouble with, with the cancer and his prognosis is not good. We give him another thing to deal with. So, um yeah, it, it is not good. So we want to make sure that we do. We keep hylax for everyone that comes in and assess risk. Obviously, if it's a 17 year old playing football every single day, um come in for a chest infection one day admission, you don't have to. Um, if you feel a bit, a bit of sympathy, you can give him some stockings, you can put him, uh, put, put some stockings on him for one day and then he's gone. Um, no issues there. You can definitely back that he's 17. You don't need to have media prophylaxis. On the other hand, if you have someone who's 65 background of uh, previous breast cancer free of cancer now, but um not, not really mobile, a homeo with a stick. She normally mo mo mobilizes with a stick. You wanna more likely consider prophylaxis with um subcutaneous Benz Barin. So um yeah, so mechanical is like the stockings I was talking about. So you can either, you can either decide whether you wanna give them injections. This is again um Tenzin. Uh that's why we give it in our hospital. Um Tenzin is a subcutaneous injection given to your stomach. Some patients don't like it, but um it has to be done. Um As long as you prescribe it, if they refuse it, it's, it's on the patient if they have capacity. Um But you have to prescribe it, so you've done your job. Um And if you feel like this patient does not need tensor power and subcutaneously, you can give them stockings or you can give them this. Um Oh sorry, someone is not able to join. Um I think the presentation is working but I uh notice events starting soon. Oh, please. I would and everyone else see the presentation because um I can, can you now see the presentation or? So wait, you guys can see. Ok, fine. Refresh the page, refreshing fixes it. Ok. Is it working now? I think it is working. Um But yeah. Ok. Um so if you guys can refresh if it doesn't work for you and see if it works. I mean, I'm more than happy to share the presentation eventually. Anyways. Can you guys hear me or is my video working? Yes. Ok. I think you can continue. That's fine. Ok. Um Yeah, so two types of VT prophylaxis, either stockings or uh IPC sleeves. Uh, these are like these um um machine uh machines that cause compressions, uh just to promote um venous flow and other, other, the other, other option is obviously giving them subcutaneous tenar and these are the risks. These are the patients that you need to, uh, make sure that you give the prophylaxis for surgical patients. Um, for sure, twen 14 to 28 days depending on what surgery they have. You have to give them BT prophylaxis, um, and medical patients depending on how, how you think if they meet any of the quality of the work, just try it part of me to be safe. You want to, um, you want to anticoagulate them pregnant people as well. Yes, you can give them low molecular weight, Tenzin. So, um, Yeah, that's, those are the main methods of et prophylaxis. It, it, it takes like two minutes when you, uh, when you, when you do it, um, it's just a two minute thing after you prescribe your medications for the, for the patient, you just do a quick assessment and then prescribe the prophylaxis. So this is a cascade, obviously. Uh I'm not even, this gets me confused at times as well. Uh, but how, how anticoagulants work is they eventually don't let it to get to the stage where it forms a fiber and eventually a clot at different parts of the cascade. That's your aim. So it will not break down the clot that's already formed, but it will stop forming any more clots. So you have uh Diro inhibitors, um 10 A inhibitors warfarin. Um you know, different factors are involved. Um But thrombolytic thrombolytic agents like alteplase, um Lalas streptokinase, I mean, it's not used anymore. It's, it's quite back in the day, but these are uh tissue plasminogen activator. So they activate this, they are like a catalyst for this and eventually um plasmin which is a breakdown which breaks down clots. So this whole bit is for your anticoag anticoagulants and this is for your thrombolytic agents. So that's the difference. That's where they act. So if you want to reverse someone's anticoagulation, you have to give the specific anti antidote to these factors. So, like chronic stomach acid, um protamine and all that So it's all, it's all different um uh antidote. So you have to make sure you give the right antidote because if you give someone um antithrombin, but they've got um 10 A inhibitor, like it might not work. So also you need to get a involvement when you wanna reverse someone's um someone's bleed and they're already anticoagulated at home. So, yeah, this is um ok, so I think that's, that's the end of the, the main part of the lecture. I've just got like um a few M CQ questions that you guys can. Um what I would suggest is maybe just put down your um answers in the chat box. So I know if you have an audience. Um And um we can um and I've got one clinical scenario which we can get some involvement as well and then, um and then yeah, and then that should be it. So we'll run through these MC Qs and then quick, quick scenario. Um And then we should be done. Um Any questions to now anything else uh that I was unclear about before we get into MC Qs? Because now is where um you guys need to think and, and try answering these questions. Uh If you do, I'll be happy but uh no pressure. Um we'll go forward if no one has any issues. Um So box, that's fine. She's walking in the background. That's OK. So first question, um which of the following is not a predominant symptom of P EI will give you like 30 seconds if you guys want to put your alphabets in the chat box. This is also a race for the fastest Wi Fi uh Mario. Mario has been consistent the whole time. Got anyone else. OK. That's fine. So that's d that's correct. High fever. That's correct. Next question with blood vessels are primarily affected in pe um That's good. Yeah. Good. Good for people. That's good. Valentine. Um Second question, which blood vessels are commonly affected in pulmonary embolism. So, uh I'll wait for your answers. Your pulmonary veins, coronary arteries, pulmonary arteries and the how many weights? Ok. Ok. So if you think about the, if you think about, yeah, it's uh it's a pulmonary arteries. So if you think about how, how, how um how the system works, the veins come to your right side. Yeah. Arteries. Yeah. The veins go to your right atrium into your right ventricle and eventually it goes into the pulmonary arteries. So how you remember is anything that comes out of the heart is an artery, regardless of whether it's oxygenated or deoxygenated. The only deoxygenated vessel that we have coming out of the heart is the pulmonary artery. So it is normally the arteries that get clogged up. Uh Oh, so it's got issues. Um Do you wanna re refresh your page s it and see if that works regardless. I will send this presentation to everyone. I mean, whoever, whoever wants it. Um, oh, people got issues. Uh, we can refresh, I guess. Do I need to refresh my page as well? Um, can someone see us or can someone see? Yeah. Can we, can we just get like at least 10 people that can see the presentation? Yeah, because I can hear you perfectly but I don't know, maybe try refreshing the page and see if it works. That's fine. I'll refresh my page as well. Can you guys hear me now dear? Can you hear me? Yeah, I can hear you. Ok, fine. Can just someone just confirm in the chat as well? So I've got a me too. How does that? Does that mean? Me too. Not working or me? Two working? I don't, mine works. Um Maybe I think we'll just to everyone. So what is the well score used in pe um, determine the need for surgery to assess the likelihood to measure oxygen levels of the calculated long term survival? Um ABCD. Which one? Which one do you guys think? Yeah. Yep. Um and PSE on the other hand, is, is the mortality after you have a pe you assess mortality within 30 days? Yeah, that's good. Yeah, we'll go to the next question. Um, which of the following is not an anticoagulant. Um So we discussed the different anticoagulation anticoagulants versus thrombolytics. Which one, which one of these are not? Yeah. Yeah. T Yeah, that's a um that's an, that's a that's a thrombolytic agent. So this is lots of different, the rest of them all different kinds of anticoagulants. So that's good. I think that's the most. Yeah, so that's fine. That's fine. Thank you. Yeah, thank you, Valentine. So this is a clinical scenario I've put up, I mean, we know for sure it's gonna be one of the, the one of the discussion topics, but I just wanna go ahead and see how, how we navigate this. This um this is a this is gonna be the last bit of the lecture. I just wanna see how we, how we how we as doctors are gonna navigate this patient. So um I'll read the situation, I'll read the scenario, sorry. Um which is a 45 year old man uh presented to Ed uh with complaints of sudden onset shortness of breath that began the previous night. He reports difficulty sleeping due to breathlessness and describes a vague non radiating, radiating chest discomfort. He denies any cough fever or recent illness. He generally fit well with no significant past medical history, no recent surgeries and no known risk factors for blood clots. He does have ever mention a long haul flight to Europe one week ago. So this is a scenario. So now what what, so given that this is this patient is on the list for you to clock. What's the next thing you wanna know before you see the patient? What are the, is there anything that you wanna know before you go see the patient, like something that's recorded. Anything that you wanna know. Uh This is what was told to you by registrar and he's asked you to go see this patient. Um Anything else you wanna know about this patient before seeing the patient? Like anything more that you think? Oh, you would just go see the patient straight away. Yeah, he sat side on the previous question. B so it was a unless you, unless you were one of the previous questions from before. Um But yeah, um besides um we moved on. Yeah, it's a clinical scenario now. Um So yeah, he sat, yes, you wanna know, you wanna know his observations. So his saturations, heart rate, BP and all that. So these are his observations as of. Um So he's, he saturate 93% on 4 L. He tachypneic, his heart rate is high. Um He's got sinus tachy on E CG. Um Actually, he's got a different E CG which I'll show you later on. I just say, I think he's, he's tachy. Um Actually it is sinus tachy. Yeah. BP is slightly on the lower side, although not really below 90 at the moment. So he's not uh we're not thinking about thrombolysis yet. Um Although it could be saturate at any point. Uh and then you see slightly distended jugular veins and um lungs are clear on auscultation mo P ES can have clear x-rays and clear uh lung auscultations and they can still have massive pe so uh clear lungs and clear uh chest X does not mean there's no pe unless you can see a clear infarction on the X ray. But yeah, so you do an E CG um you do a chest X ray, you do ad dimer which is 650. So it's uh in favor for a pe um you do a well score. So now given his history, uh I will bring up the well score scoring system and I want you to let me know what do you think his well score is before we go on to the well score. What do you guys think about the x-ray? Do you think this is um is there anything that you can see that's concerning any pneumothorax or a any cardiomegaly, any broken grips? If you can, I mean, to be honest, we can't see it on a chest X ray, but anything that you can see on this X ray, is it clear to you guys or is there a consolidation somewhere that you can see might, might have to zoom in if, if, if she can't see it clearly, I'll wait for a bit to see if anyone can see anything in the meanwhile, you can also have a look at the ECG um and let me know what you think. Um what can you see in the E CG that we spoke about before there's a certain pattern for um P ES that you can see. Um I'll let you know. So this, this X ray is pre pre clear, it's nothing I can see. Uh no clear consolidation, clear um clausen angles, no cardiomegaly, no pneumothorax, no clavicle fracture um on the E CG. However, you can see this um I obviously picked, picked an E CG with S one Q TQ three T three situation where you can, where you can see there is a right heart strain. So s more prominent S wave s wave here, you have a very deep or more prominent um Q wave here. If you compare Q waves to the rest of the leads, this Q wave is more deepened if you can, if you can appreciate that. And the last thing is um inverted T wave. So this is your S one QT 33 pattern in someone with a pe showing right heart strain. Uh Obviously, you can check for any bundle branch block later on. But when you see this, you've got a DMA which is 650. Um The patient is desaturating. It's like it is like there is no, no nothing else for you to be for you to do. The last thing is probably a while ago. Um Given the history, this man uh who is, who is uh 45 a recent long haul flight, no medical history whatsoever. These are um these are his observations. Um He's tachypneic, tachycardic oxygen sat at 93% and this is CG um da raised now I want you to calculate his well score and just put it on the chat um so we can see what you guys think. I mean total score. If you guys want to calculate I'll give you a minute. Is anyone here? Uh wait can you hear me? I can hear you I can hear you every single time. Yeah. Ok, because I think, um, for some people it's not working now. Ok. Ok. I mis good's good stuff, Miriam. Um, 4.5. Yeah. Yeah, that's just, yes, I can definitely go back to the history. No medical history whatsoever. Um, reasonable long haul flight, no risk factors. These are sacs sack of Nick. This is ECG chest X ray and this is his, he was 4.5. That's actually correct. 5.5 as well if he has MT says, yeah. Um, um, you can 4.5 to 5.5. Yeah. So you have a somewhat high levels score as well. Um, so then you go on with the C TPA and then you see a massive like saddle pe literally as big as this. Can you see that filling defect here? Um, they, they, these patients are high risk, they can desex at any point. You have to get it involved, you have to get your HD UI T uh, whatever the team is in your hospital, that's that takes kind of really, really um uh sick patients for organ support. You have to get them involved that you, that this patient is high risk for high risk. He's got a pe he's stable now, although on 4 L, but he can need sat at any point, he can go into hypertension, hypertensive shock at any point. So he will need to have thrombolysis at that point. So this is a saddle p. So this is just a cartoon picture of a sp so literally where it has to supply both the lungs, it is blocked. There is barely any way for any blood to eventually go reach any of these. Your whole lung is going to have an infarction eventually. Um, if you do not do anything about it just yet. Um, so this is a saddle p when you see some with a saddle P, it's, it's, it's, it's not the best prognosis. Normally, I've only seen one, since I've started working, but, um, it is possible quite a big one and someone has no history whatsoever. Um, maybe not really common for someone with clear history. I mean, like a clear back or no, no back, no risk factors, but it can happen. I think that's it. That's, that's, that's all of my lecture. It has been a one on one lecture with Marriam and then Jalal and a few other people as well and sed although, um, I would, um, appreciate it if you do scan the QR code on the screen at the same time for our feedback via grands CPE. Um It's been a pleasure doing this talk. II hope I was helpful and I've given you more confidence um going forward um wherever you are as in whatever year you are or you just graduated. I hope that it has given you some confidence to initiate plans um as a junior doctor and then escalate as needed. Is there any questions that you have before we, before we finish? I'm more than happy to answer it. Uh And I people that missed the, the lecture. Uh I'm sorry, I don't know what to do, but I'm more than happy to share the, the, the, the presentation. Um And yeah, and anything else if you need any help regarding the NHS or anything like that? I'm more than happy to help you guys. Yeah. Yeah, dear, you can go ahead. Yeah. Hey guys. So if you guys can fill out a feedback form and once it's filled out, um the certificate will be sent to your email. So, yeah, and sorry about the problem. Uh I'll try to make sure it, it gets fixed for the next talk. No worries. And maybe we can give you guys a few minutes to fill out the feedback form. Anything that can indicate a S pe doing investigation prior to actually seeing, um You can see the S one Q three T three as well, but maybe the level of desaturation that the patient is having. So someone with a pe might not desaturate as much as with the S pe because there have been patients that uh might be short of breath only, but they might not desaturate to 89. They might be at 94 or like 93 on 1 L. But someone with a really huge pe they might be on like 8 L or like 15 L. So more um clinically when you see them, if, if they are really bad. Um and you see a side of the P on the, on the C TPA, that's, that's why. Um But if, if the pe is more, more down, more, more lower down like in one of the other, other veins or like one of the um a more not exactly the bifurcation a bit more lower down. Um The, the, the um they're not, they're not prone to desaturate really quick, although they will be hypoxic uh eventually it will resolve, but someone with S pe prognosis is not the best. Um And there's a high risk, like I said, you have to involve itu and your diagnosis must be high risk pe they can desaturate at any point and your plan should be, if they, if they do go into hypertensive shock, you have to uh thrombo or consider thrombolysis thrombolysis. And I mean, obviously make sure they don't have a bleeding, a ble uh bleeding elsewhere as well. But yeah, that's, that's one way you can find out if someone's got a really big pe Yeah. Any, any other questions? Ec GS one Q three T three use if you see that. Um It's a good spotting. If you do that as a doctor consultant will be like, ok, that's good. Um But C TPA is the gold standard. If you have nothing on ce CG, nothing on D I, there's nothing you do. A CT PDI must be raised. You do a C TPA and you find out it's a pe everything else you've done before forgetting about it because you, you diagnosed you with the C TPA. So yeah, and that's it. Yeah. Any more questions, I'm happy to answer. You can, you can email me or whatever. Um or um anyway, you can get through and then I can, I'm more than happy to answer your questions or any regarding anything regarding working NHS or anything like that. So it's fine. OK. So before we end, our next talk is on the sixth of October this Saturday by Doctor Fava on approach to geriatrics. So, um and also we have ABL S course that's coming up um which is in person in Sophia. So if you want to know more information, um please just have a look at our Instagram page or messages. So if someone is finished with the feedback form, can you please write it in the chat? So, we can maybe wrap up for today. Yeah, sure. Uh yeah, I can, yeah, we can give it to you, we can send it to you via email. Not a problem. A shock. Ok, thank you guys. Um see you guys for the next talk and I'm really sorry about the problem today, but uh I'll make sure for the next talk the problem gets fixed. So bye bye. See you. Bye.