Note the subtle venous congestion and edema of the right hand and wrist in this patient with an upper extremity deep venous thrombosis (Paget-Schroetter Disease),
Here is a slightly different twist on Virchow’s triad, and one that I had not seen before until yesterday: a spontaneous upper extremity DVT (Paget Schroetter Disease) in an otherwise healthy person with no risk factors. It’s uncommon, but not a complete zebra. The pathophysiology and subsequent management also differs from your traditional DVT, so I thought it was worthwhile to highlight some of the features that make it unique.
The EMBER: as always, a collection of interesting information about this topic from around the web.
Paget–Schroetter disease – Wikipedia
First rib resection for Paget-Schroetter Syndrome – YouTube
Spontaneous upper extremity venous thrombosis (Paget-Schroetter syndrome) – Up To Date
I was going to use this post to talk about potential spaces in the body until I made the mistake of mentioning it to a surgical friend of mine (yes, I have them) who got all upset that I was really talking about a compartment and not a potential space (apparently I’ve been inappropriately mixing anatomical spaces my entire career). While the definition of a compartment versus a potential space is still debated hotly among anatomy nerds (yes I called you a nerd), for an EP there’s nothing like a dramatic case to remind you that not all potential spaces (or compartments or whatever, hey will you relax please?) are created equal.The elderly and morbidly obese often have a lot more “potential” to extravasate into these spaces.
In the case pictured here, a minor fall in a small woman with abundant loose adipose tissue in her arms led to substantial blood loss before spontaneously rupturing through the skin. She arrived to the ED in class III hemorrhagic shock.
So I guess if you want to be clear about it, old people on Coumadin have a lot of “potential” to bleed copiously into what seem like rather small compartments. Okay there, does that make you happy? I know it does.
If you would like to review the difference between a compartment and a potential space here is a mind-numbing review for you. Anatomical spaces: a review. Newell RL. Anatomy Unit, School of Biosciences, Cardiff University, UK. Newell@cardiff.ac.uk
New STEMI equivalents keep showing up all the time. What is a STEMI equivalent you ask? For those ECG nerds out there (you know who you are, yes the one’s with the calipers in my ED) it is the rapidly expanding number of ECG patterns, beyond the traditional ST elevations, that suggest an acute coronary occlusion and therefore require emergent revascularization.. Here is one I was unaware of until just recently. Add it to your list.
Dr Smith’s ECG Blog Back Pain Radiating to the Chest in a man in his 40’s
Appropriate Cardiac Cath Lab activation: Optimizing electrocardiogram interpretation and clinical decision-making for acute ST-elevation myocardial infarction