COVID and Clotting: How to Identify, Assess, and Treat Clotting Disorders in COVID-19 Survivors

Treating patients with acute and chronic clotting conditions is not new to rehabilitation professionals. We even have clinical practice guidelines around how to do so safely. However, what is new is the increased risk of newly acquired clotting conditions among post-COVID-19 patients. Those of us practicing in emergency and outpatient settings are uniquely tasked with identifying these patients in their facilities, possibly upon presentation for unrelated conditions or for rehabilitation due to long-COVID.

A Clotting Case Study

A 23-year-old man presents to emergency after a fall. He reports pain, sensory changes, and decreased function in his left leg. He is unable to walk and reports mild shortness of breath. Bloodwork and imaging studies reveal a large clot in his left common iliac vein, as well as several smaller clots throughout his body and lungs. An emergency mechanical thrombectomy is performed, with complications of significant blood loss. This patient now presents as an L3 spinal cord injury due to ischemic trauma at the level of injury, as well as brain trauma that is also due to generalized ischemia. Here’s the strange part: this patient has no previous medical history, except for (you guessed it) a recent COVID-19 infection.

The Relationship Between COVID-19 and Clotting

Before COVID-19, it was well established that inpatient care for a respiratory illness was a risk factor for thromboembolism (TE) and increased the mortality rate from pulmonary embolism (PE). 9 Also before COVID-19, the average prevalence of deep vein thrombosis (DVT) in the general population was .001 percent, and the risk of that DVT developing into a PE was about 40-50 percent.2 As rehabilitation professionals, we typically compensate for some increased risk of these events after surgeries, cancer, and long-term immobilization (an increase in risk to about 1 percent) using the Well’s Criteria.15

The prevalence of PE in respiratory patients after the emergence of COVID-19 was 2 to 2.7 times higher among those who had contracted the virus than those who had not, regardless of hospitalization.11 Additionally, PE was regularly found in patients who previously received thrombolytic therapies. Overall, an average 24 percent cumulative incidence of PE was discovered in patients after COVID-19 pneumonia.3 Multiple studies have reported the increased risk of DVT to be between 7.8 and 11.2 percent.14,4 It has become clear that COVID-19 produces a state of hypercoagulation in many people.

Banner Promoting MedBridge COVID-19 Toolkit with Image of COVID-19 Virus

Considerations for Assessment and Treatment

What does this mean for rehabilitation therapists who are now treating patients with current infections or histories of COVID-19? Well, that’s most of us now, so here are some considerations:

Follow the symptoms. Most of us have seen DVTs, so we know what to look for. If it looks, acts, and sounds like a PE, it probably is. Previous and ongoing use of antiplatelet and thrombolytic therapies did not impact the prevalence of clotting after COVID-19, so don’t let that sway your judgment.11 Many of these patients will already be short of breath, but a sudden change in oxygen saturation response to activity accompanied by tachycardia should raise a red flag.

Know the risk factors. Patients with a recent history of COVID-19 who experienced clotting disorders were more likely to have a BMI greater than 30. Multiple sources report hospitalization for COVID-19 is not a risk factor.11,9 In one study, 52 of 72 patients with clotting were not hospitalized.12 The patients were also more likely to be male6 and younger.1 The strongest factors associated with PE were a history of PE, followed by obesity. In addition to these factors, hospitalized patients also demonstrated a progressively elevating D-dimer12 and higher pulmonary artery pressures.13

Use your tools. We have several tools at our disposal to help us spot venous TEs and PEs, so use them. Check out the Well’s Clinical Prediction Tools for DVT and PE. The Geneva Scores for DVT and PE are also evidence-based and may already be in use by some facilities. Additionally, Geneva accounts for recent respiratory failure and obesity as specific criteria, two factors known to be associated with COVID-19 related clotting risk. Therefore, Geneva might be a better tool for this specific population.

Understand bleeding risk. Heparin and low-molecular-weight heparin are commonly given to patients hospitalized with COVID-195 and patients with clotting. The evidence is still out on oral blood-thinning agents for those with COVID-19 who are non-hospitalized. However, patients taking antiplatelets, anticoagulants, and thrombolytics are still at risk for developing these conditions. They are also at increased risk for bleeding with falls and other injuries when on these drugs.

Considering the bleeding risk of your patients may seem counterintuitive in the context of hypercoagulability, but in a hospital setting, most patients will be on some form of therapy to reduce clotting risk. In the case study discussed at the beginning of this article, the patient’s primary reason for presentation to emergency was a fall and his intraoperative complications were due to bleeding. The older adult population with an increased risk of being hospitalized with COVID-19 will have a higher incidence of being on medications with anticoagulant effects to treat other comorbidities. Therefore, we must balance the concerns of bleeding with the risks of clotting.

Current data suggest we are looking at a 24 percent increase in risk for clotting disorders, with an estimated 5 percent of all people who have had COVID-19 infections having PEs.10 As therapists, we should use our knowledge and tools to identify and progress these patients quickly to emergency care to improve overall patient outcomes. With an estimated 38 percent of COVID-19 related PEs diagnosed on first contact8 with the medical community, leaving 62 percent to be diagnosed later in the episode of care, we are the frontline.

To learn more about the impacts of COVID-19 on patients with new cardiovascular and pulmonary (CVP) and critical-illness-related impairments, MedBridge instructors Angela Campbell and Ellen Hillegass offer a three-part series that presents clinical concepts for COVID-19, assessments and outcomes in the outpatient setting, and case studies on post-COVID recovery.

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