Early reports have shown that COVID-19 is most likely causing a hypercoagulable state, however the prevalence of acute VTE and exactly how to treat it is an evolving area. Limited data suggest pulmonary microvascular thrombosis may play a role in progressive respiratory failure. However, most evidence is limited to small retrospective trials. As we wait for more evidence, clinical decisions have to made at the bedside and decisions about pharmacological prophylaxis are starting to emerge. In this episode I sit down with a special guest that is new to REBEL Cast to talk about the dilemmas involving COVID-19 and thrombosis....Read More
Background: In patients with ICH, antiplatelet therapy is withheld due to the perceived risk of hematoma expansion. Often, these medications are either not restarted or there is prolonged delays until they are restarted, but the risk of occlusive vascular events might be higher without resumption of antithrombotic therapy. A meta-analysis of observational studies found no difference in the risk of hemorrhagic events and a lower risk of occlusive vascular events associated with antiplatelet therapy resumption after any type of intracranial hemorrhage (ICH); however, randomized trials for antiplatelet efficacy in occlusive vascular disease have excluded patients with a history of intracerebral hemorrhage. Due to the paucity of evidence, no guidelines have strong recommendations about long-term anti-platelet therapy after ICH. The RESTART Trial  aimed to address the question of whether or not to start antiplatelet therapy following an intracerebral hemorrhagic stroke. ...Read More
Superficial venous thrombosis refers to a clot and inflammation in the larger, or “axial” veins of the lower extremities and superficial thrombophlebitis refers to clot and inflammation in the tributary veins of the lower extremities. While we previously thought of this as a benign entity, we actually found the superficial venous thrombosis has been associated with concomitant DVT and PE.
Small, superficial clots can be treated with compression, NSAIDs, and elevation. These patients should be seen for follow up within 7-10 days to make sure the clot has not progressed.
Clots that are longer than 5 cm should be treated with prophylactic dosing of anticoagulation: fondaparinux 2.5mg subq once daily for 45 days or enoxaparin 40 mg subq once daily for 45 days.
Clots that are within 3 cm of the sapheno-femoral junction should be treated the same as a DVT.
A superficial thrombus could mean there is a deeper clot elsewhere, even in the other leg! Take a good history, perform a thorough physical exam and consider a bilateral lower extremity DVT study in concerning patients.
Background: TXA is a synthetic lysine derivative that binds with the lysine site on plasminogen and inhibits fibrinolysis. TXA is not a new drug. Studies from the late 1960s and early 1970s have shown reduced bleeding and need for transfusions in many surgical and medical settings. Fast forward to today and we are finding all kinds of uses for TXA other than trauma including post-partum hemorrhage, epistaxis, hemoptysis, gastrointestinal hemorrhage, and many more....Read More