Saturday 30 May 2009

Lethal In Low Doses

Box 1: Nine ingestants that can be
lethal in toddlers in low doses
• Calcium channel blockers
• Camphor
• Imidazolines (eg, clonidine)
• Cyclic antidepressants
• Lomotil
• Opiates
• Salicylates
• Sulphonylureas
• Toxic alcohols
Note: Not in order of lethality

Friday 1 May 2009

Preventing Recurrent DVT

A patient with successfully treated
DVT remains at increased risk of
DVT or PE for life and will need prophylaxis
at times. Prophylaxis (with,
for example, enoxaparin 40mg daily)
should begin 12 hours before elective
surgery.
In orthopaedic surgery, it should
be continued at this dose for three
weeks after discharge from hospital2.
Early remobilisation and compression
stockings should be used routinely
for all surgery. Intra-operative
calf compression machines are often
used in prolonged elective surgery.
High-risk medical patients (eg,
those likely to be inpatients for more
than five days) should receive routine
prophylaxis whether or not they
have had a prior DVT.
Seek advice if the patient has renal
impairment because LMW heparins
accumulate quickly in patients with
moderate to severe renal failure.
All women with previous DVT or
artificial heart valves should receive
daily heparin prophylaxis during
pregnancy. Haematological review is
recommended in those with diagnosed
thrombophilia (deficiency of
anti-thrombin III, protein C or S,
mutations of factor V or prothrombin
genes), as more intense prophylaxis
may be needed in some.
Patients with a past history of
DVT who are planning air travel for
more than four hours should be
given recommendations in writing:
• Self-inject 40mg enoxaparin before
each separate flight (not including
refuelling stops)
• Ask for a seat with good leg room
• Accept every non-alcoholic
beverage offered
• Minimise alcohol consumption
• Perform in-seat exercises recommended
by the airline.
National guidelines do not recommend
frequent walking around the
cabin because of the risk of turbulence.
Aspirin does more harm than
good in air travellers.
References
Current Diagnosis of Venous Thromboembolism
in Primary Care: A Clinical Practice Guideline,
American Academy of Family Physicians and
the American College of Physicians.
Annals of Internal Medicine: p57- 62: Vol 5:
No 1: January/February 2007
1. Palareti G., Cosmi B., Legnani C., et al. DDimer
Testing to Determine the Duration of
Anticoagulation Therapy. N Engl J Med 2006;
355:1780-1789, Oct 26, 2006.

Preventing Recurrent DVT

A patient with successfully treated
DVT remains at increased risk of
DVT or PE for life and will need prophylaxis
at times. Prophylaxis (with,
for example, enoxaparin 40mg daily)
should begin 12 hours before elective
surgery.
In orthopaedic surgery, it should
be continued at this dose for three
weeks after discharge from hospital2.
Early remobilisation and compression
stockings should be used routinely
for all surgery. Intra-operative
calf compression machines are often
used in prolonged elective surgery.
High-risk medical patients (eg,
those likely to be inpatients for more
than five days) should receive routine
prophylaxis whether or not they
have had a prior DVT.
Seek advice if the patient has renal
impairment because LMW heparins
accumulate quickly in patients with
moderate to severe renal failure.
All women with previous DVT or
artificial heart valves should receive
daily heparin prophylaxis during
pregnancy. Haematological review is
recommended in those with diagnosed
thrombophilia (deficiency of
anti-thrombin III, protein C or S,
mutations of factor V or prothrombin
genes), as more intense prophylaxis
may be needed in some.
Patients with a past history of
DVT who are planning air travel for
more than four hours should be
given recommendations in writing:
• Self-inject 40mg enoxaparin before
each separate flight (not including
refuelling stops)
• Ask for a seat with good leg room
• Accept every non-alcoholic
beverage offered
• Minimise alcohol consumption
• Perform in-seat exercises recommended
by the airline.
National guidelines do not recommend
frequent walking around the
cabin because of the risk of turbulence.
Aspirin does more harm than
good in air travellers.
References
Current Diagnosis of Venous Thromboembolism
in Primary Care: A Clinical Practice Guideline,
American Academy of Family Physicians and
the American College of Physicians.
Annals of Internal Medicine: p57- 62: Vol 5:
No 1: January/February 2007
1. Palareti G., Cosmi B., Legnani C., et al. DDimer
Testing to Determine the Duration of
Anticoagulation Therapy. N Engl J Med 2006;
355:1780-1789, Oct 26, 2006.
2. TGA-approved product information for

DVT FACTS

1. The surgical or sick medical
patient is the classic high-risk
person for DVT.
2.High clinical suspicion and a
positive D-dimer mandate further
investigation.
3.If suspicion is high, treatment for
DVT or PE should be started as
soon as the diagnosis is
suspected, not delayed for
confirmatory imaging studies.
Many DVTs are unprovoked,
especially in males.
4.Testing INR too often wastes
resources and leaves you making
frequent dose changes to ‘chase
your tail’.
5.Electing to continue warfarin for
12 months delays recurrence of
VTE but does not eliminate it.

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