ALiEMU Capsules Module 8: Venous Thromboembolism

We are proud to present Capsules Module 8: Venous Thromboembolism, now published on ALiEMU. Here is a summary of the key points from this outstanding module by Drs. Jill Logan and Doug Gowen.

Go to ALiEMU module

Summary: Venous Thromboembolism

Venous thromboembolisms (VTE) constitute disease states with a wide array of presentations ranging from incidental findings to imminent mortal peril. Treatment of these disease states necessitates a comprehensive understanding of the delicate balance of the pro-coagulant and anti-coagulant forces within the body and their means of manipulation through pharmacologic intervention. This Capsule will assist the reader in their understanding and application of current therapeutic interventions for VTE as well as invite the reader to explore the evidence behind these recommendations. This preview highlights a few Capsules in this module.

Oral Anticoagulation for VTE

Warfarin has traditionally been the best (and only) available oral anticoagulant in our arsenal, however, a substantial practice shift has occurred with numerous direct oral anticoagulants (DOAC) now available. These DOACs have been approved to treat both deep vein thromboses (DVTs) as well as pulmonary embolisms (PE) and may now be considered first-line in patients without cancer.

 

Warfarin is notorious for drug-drug interactions but care should still be used with the DOACs when combined with p-glycoprotein inhibitors and inducers.

Parenteral Anticoagulation for VTE

At times, parenteral anticoagulation may be indicated over oral therapy. For example, low molecular weight heparins (LMWHs) remain the drug of choice for patients with VTE and active cancer. Additionally, when using warfarin, bridge therapy is recommended for a minimum of five days to assure adequate anticoagulation while achieving a therapeutic INR. Heparin therapy offers an advantage in patients who are unstable or in whom surgical intervention may become necessary due it’s relatively short duration of action and ability to be reversed with protamine.

Some DOAC agents necessitate treatment with parenteral anticoagulation for 5 days prior to initiation for VTE.

VTE in Pregnancy

Pregnancy is a hypercoagulable state and the risk of VTE increases as gestation progresses. LMWHs are the treatment of choice in pregnancy, however, therapeutic doses of subcutaneous heparin may also be an option. The DOAC agents have not been tested in pregnancy and due to unknown effects on the fetus, their use is not recommended.

Warfarin may be teratogenic and should not be used in pregnancy.

VTE in Pediatrics

LMWHs have become the agent of choice for the treatment of VTE in children, however, there is very little published clinical data to support one therapy over another. Unlike adult patients receiving LMWHs, therapeutic drug monitoring is recommended for all pediatric VTE patients receiving this therapy.

Use extreme caution when prescribing anticoagulation in pediatrics to avoid dosing errors due to concentration differences among anticoagulants.

Breakthrough Clotting

From time to time, the ED provider may be presented with a patient on therapeutic anticoagulation presenting with a new clot or clot worsening. After assessment of compliance and investigation of potential drug-drug interactions to ensure therapeutic anticoagulation has been maintained, therapy may be switched to LMWH therapy. If the patient was already receiving LMWH, a temporary dose increase by approximately 25% may be considered.

Many of the DOAC agents have different dose recommendations based on indication. Ensure patients with breakthrough clots were prescribed the correct DOAC dose before considering the therapy a failure.

Hemodynamically Unstable PE Management

Thrombolytic therapy may be considered for massive PE and some select submassive PE patients. Alteplase is approved for use in massive PE as a 2 hour infusion of 100 mg. Patient acuity may necessitate more rapid intervention and administration of thrombolytic via intravenous push has been suggested. Alternatively, some evidence suggests that lower thrombolytic doses may be appropriate in submassive PE patients.

Resuscitation efforts are recommended to continue for 15-20 minutes following thrombolytic administration in cardiac arrest situations.

Course Contributors

Role Team Member Background
Authors Jill Logan, PharmD, BCPS @EMPharm EM Pharmacist, University of Maryland Medical Center
Doug Gowen, PharmD, BCPS @DougEDPharm EM Pharmacist, Glens Falls Hospital
PharmD Reviewers Michelle Hines, PharmD, BCPS @mEDPharmD EM Pharmacist, University of Maryland Medical Center
Paul Takamoto, PharmD @ptakpharm EM Pharmacist, University of California San Francisco
Associate Editor Craig Cocchio, PharmD, BCPS @iEMPharmD EM Pharmacist, Trinity Mother Frances Hospital
Physician Reviewer David Juurlink, BPharm, MD, PhD, FRCPC @DavidJuurlink Professor of Medicine, University of Toronto
Copy Editor Meghan Groth, PharmD, BCPS
@EMPharmgirl
EM Pharmacist, UMass Memorial Medical Center
Creator and Lead Editor Bryan Hayes, PharmD, FAACT, FASHP @pharmertoxguy EM Pharmacist, Massachusetts General Hospital; Assistant Professor of EM, Harvard Medical School

 

Author information

Bryan D. Hayes, PharmD, FAACT, FASHP

Bryan D. Hayes, PharmD, FAACT, FASHP

Chief Science Officer, ALiEM
Creator and Lead Editor, CAPSULES series, ALiEMU
Clinical Pharmacist, EM and Toxicology, MGH
Assistant Professor of EM, Harvard Medical School

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Top 5 Reasons to Join the 2017-18 Chief Resident Incubator

“Leadership and learning are indispensable to each other.”
– John F. Kennedy

Every year without exception, a new set of Chief Residents are chosen at each Emergency Medicine program. They are always excited for the position, but hardly prepared for what’s to come. We have now had 2 successful ALiEM Chief Resident Incubators and are extremely excited and thrilled to launch the third 2017-18 ALiEM Chief Resident Incubator.

If you are a Chief Resident, here are the top 5 reasons why you should join the Incubator.

Top 5 Reasons To Join

1. ALiEM Chief Resident Incubator Team: Continued Expansion and Improvement

We are a continually growing and expanding team. Dr. Fareen Zaver, a previous Chief Resident who participated in the inaugural 2015-16 Chief Resident Incubator is taking the lead as the Chief Operations Officer. The Senior Advisors, which include Dr. Maggie Sheehy, Dr. Adaira Chou, Dr. Nikita Joshi, and Dr. Michelle Lin, will continue to guide this powerhouse group in a longitudinal networked curriculum. We also are continually improving the experience and curriculum month-to-month and year-to-year.

2. Amazing Mentors

Over the last 2 years we have had an all-star mentorship experiences on Google Hangouts catered toward the Chief Resident experience. They will help you dive into conflict resolution, build your own stellar CV, and through a variety of opinions and practices will make you the best Chief Resident your program can ask for. The second half of the academic year will focus more on helping you develop a career niche, plan for life after residency, and work towards faculty development or excelling in the community environment.

Furthermore, we are bringing back some star Chief Resident alumni to be Core Champions, to help provide you a more customized, near-peer mentorship experience. Pick their brains and learn what they WISHED they had known before becoming Chief Resident.

3. Publications and Educational Initiatives

We loved seeing how much the Chief Residents wanted to publish over the course of this year. We are excited to work on even more opportunities for Chief Residents to publish together and produce more educational content. We launched a free residency In-Service Training Exam prep book (now with the 2nd edition already!). Also the Chief Residents were eligible to publish on the ALiEM blog site, where each post typically received 500-2,000 views each. Take a look at a small slice of what we’ve published over the past 2 years on ALiEM!

  1. ALiEM AIR-Pro Series
  2. Top 5 FOAM Radiology Resources
  3. PV Card Series: ED Charting and Coding
    1. Introduction to Charting and Coding
    2. History of Present Illness and PMH
    3. Review of Systems
    4. Physical Exam
    5. Medical Decision Making
  4. Top 10 Educational Initiatives from the Chief Resident Incubator
  5. PV Card: Laceration Repair and Sutures Guide
  6. PV Card: Elbow Injuries
  7. PV Card: Knee Injuries
  8. PV Card: Hip Injuries
  9. Dear Residents: 10 Things Your Chiefs Want You To Know
  10. 5 Scheduling Software Options in the Emergency Department: An In-Depth Review
  11. EM Journal Club Reading List
  12. White Coat Investor Bookclub
  13. Dreamland: The True Tale of America’s Opiate Epidemic Bookclub

4. Mastermind Groups

We are launching a new initiative this year called the Mastermind Groups. What is this exactly? With the guidance of our amazing faculty advisors, 2 groups of 10 Chief Residents each will meet virtually to tackle both individual and systems challenges together. There synergy of energy and talent has the full support of the ALiEM and Chief Resident Incubator network and resources to make meaningful change. The idea is to challenge each other to brainstorm ideas, create and implement goals, and support each other. Not every Chief Resident in the incubator will get to be a part of these groups so stay tuned for more details after you enroll!

5. Live VIP Invite-Only Networking Events

This year, we plan to have VIP networking mixers at CORD’s and ACEP’s 2017 national meetings. Our live launch event will at the 2017 CORD Academy Assembly (Fort Lauderdale, FL) following CORD’s Chief Resident Symposium on April 27, 2017 (6-8 pm).

How to Sign Up

Visit the 2017-18 ALiEM Chief Resident Incubator home page to read more and sign up!

Author information

Fareen Zaver, MD

Fareen Zaver, MD

Chief Operating Officer, Chief Resident Incubator 2017-18
Lead Editor/Co-Founder of ALiEM Approved Instructional Resources - Professional (AIR-Pro)
Champion, 2016-17 ALiEM Chief Resident Incubator
Board Member, 2016-17 ALiEM Wellness Think Tank
Clinical Lecturer, Emergency Physician
University of Calgary Emergency Department

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