The Covid-19 High Noon: cause of death stroke, thrombosis, pulmonary embolism / update 8
The Covid-19 Hight Noon – it is also a venous high noon. Through the very current work of the Hamburg pathologist and forensic doctor Prof. Klaus Püschel, who despite advising against and prohibiting official offices of the Federal Government and the Robert Koch Institute did the only right thing in the medical sense – to autopsy those who died on Covid-19!
Quote from Prof. Püschel: „First of all, we found that the causes of death are very different. There are no ‚corona deaths, as the statistics suggest,“ said Püschel of the „FAZ“. Instead, there are „a lot of causes of death“ in connection with the corona virus. It should be clearly stated that the previous diseases played a very important role in the course of the disease, according to the legal doctor.
There is an additional danger from known or unknown disorders of the coagulation system. Patients with coagulation disorders in the family should now definitely be examined by a family doctor or a laboratory. Here, too, there is a deadly danger in the event of a possible infection with this Covid-19 virus.
The Covid-19 High Noon: „Very many causes of death“ in connection with Corona.
Zitat Prof. Püschel: „Festgestellt haben wir erst mal, dass die Todesursachen sehr unterschiedlich sind. Es gibt nicht ‚den‘ Corona-Toten, wie es die Statistik suggeriert“, sagte Püschel der „FAZ“. Stattdessen gebe es „sehr viele Todesursachen“ im Zusammenhang mit dem Coronavirus. Es sei klar festzustellen, dass die Vorkrankheiten eine sehr wesentliche Rolle für den Verlauf der Krankheit spielten, so der Rechtsmediziner.
In Hamburg, the deceased have so far been without exception multimorbid: they have suffered from several diseases at the same time, often from serious diseases of the lungs or heart, and in some cases from cancer. In addition, the dead are older. This coincides with the information provided by the Robert Koch Institute: on average, the deceased in Germany were 80 years old. According to RKI, a total of 86 percent of the deceased were 70 years and older.
Telephone call with Prof. Klaus Püschel
He experienced a big surprise in the approximately 110 post-mortem examinations of Covid-19 patients and told us about it in a personal phone call on April 23, 2020 in the early morning hours. And we discussed the consequences together.
„What is noticeable in numbers is an unusually large number of thromboses and pulmonary embolisms in about 50% of the deceased patients. All patients also showed deep venous thrombosis of the lower leg – knee – and also thigh veins as well as signs of several small pulmonary embolisms.
These then closed the pulmonary tract so that there was an excessive growth of bacteria with severe bacterial pneumonia.
Examination of the thrombosed veins of the lower leg and knee joint veins also revealed an extremely high proportion of Covid-19 viruses in the endothelium (inner layer) of the vein wall. These obviously destroyed the cell structure of the inner vein walls in such a way that the coagulation cascade, which is well known from vascular medicine, was started and led to several pulmonary embolisms in the anyway weakened, mostly bedridden patients. „
The corona infection therefore does not primarily have an effect on the respiratory tract and lung tissue, but probably primarily on other organ systems. Here especially on the system of blood coagulation and the inner skin of the blood vessels. In half of all cases, the fatal principle is venous thrombosis with subsequent detachment of blood clots, which leads to embolisms of the lungs.
The corona infection therefore does not primarily have an effect on the respiratory tract and lung tissue, but probably primarily on other organ systems. Here especially on the system of blood coagulation and the inner skin of the blood vessels. In half of all cases, the fatal principle is venous thrombosis with subsequent detachment of blood clots, which leads to embolisms of the lungs.
We then discussed possible prophylaxis and therapy options for the affected infected patients together on the phone and Prof. Püschel asked us to pass on the recommendations presented in this news to him.
Many thanks from us to colleague Prof. Klaus Püschel for his consistent medical – ethical approach and the search for clinically relevant diagnostic and therapeutic statements about Covid-19!
In the meantime, Italian dermatologists and podiatrists have also reported thrombosis on small skin vessels, particularly on the feet and toes.
The Covid-19 High Noon: leg veins and coagulation system:
Das Covid-19 High Noon – ist nicht nur ein Spruch! Sehr oft haben wir an dieser Stelle über die verschiedenen Behandlungsmethoden von Krampfadern und Thrombosen gesprochen und geschrieben – und auch über die verschiedenen Sichtweisen von Therapeuten und Patienten.
The Covid-19 High Noon – is not just a saying! Very often we have spoken and written about the different treatment methods for varicose veins and thrombosis – and also about the different perspectives of therapists and patients.
Varicose vein disease can initially be seen as a functional, chronic disease. The existing pathological function – defective, non-closing venous valves – leads to chronic changes in the skin, subcutaneous tissue and also the muscles over the years. Visible changes in the skin have different forms – from spider veins / retinal veins to strong side branches – or trunk veins.
In the advanced stage, we then regularly see chronic skin changes, from simple small brown spots to large-area brown discoloration on the ankle and lower leg (Cafe aut lait spots).
In addition to the venous disease or in isolation as an independent clinical picture, coagulation disorders – the lack of various coagulation factors – and thus there can be coagulation of the blood.
After appropriate urgent laboratory diagnostics, Covid-19 patients or those at risk should definitely be given coagulation prophylaxis. This applies to all age groups in both home quarantine and hospital.
The Covid-19 High Noon: Optical signs show pathology
The optical signs described above indicate pathological changes in the venous system and it is up to us to determine these changes. We often see surprised patients who actually only come in the spring to have ugly spider veins „sprayed away“. The specialist standard leaves us no other option – functional therapy is mandatory!
But now this: Covid-19 deceased increasingly show venous thrombosis and then fatal pulmonary embolism!
Our request for a thorough examination of the skin and deep leg and pelvic veins is all the more important. Above all, the change in the veins themselves, and here in particular those of the deep and superficial leg veins, must be taken into account by us. In addition to the hydrostatic pressure, which increases in the lower leg veins, the more venous valves are defective, the pressure caused by breathing, laughing and pressing in the chest and abdomen also plays a major role.
The Covid-19 High Noon: thrombosis!
Alternating pressure creates uneven blood flow and these irregularities can have a devastating effect on the smallest cause – the spontaneous clotting of the venous blood. We then speak of superficial thrombosis (phlebitis) or deep venous thrombosis. The causes are a lack of fluids, long periods of sitting, high outside temperatures, intensive competitive sports activities – individually or in combination – and also a virus infection. This is how travel thrombosis, spontaneous office thrombosis, sports thrombosis, flight thrombosis and now also Covid-induced thrombosis arise.
The Covid-19 High Noon: pulmonary embolism!
We will not be able to forget what the author himself experienced, in the summer of 2008. The author was intensely sporty with his racing bike every day and also cycled to work in the center of Berlin. It was a very warm summer and there was no fluid balance. And it was not yet known that there was a common varicose vein. Sure, you saw mesh veins and slightly dilated veins …
After vein thrombosis – although treated with heparin injections – there was thrombosis of the deep knee vein – and pulmonary embolism of the right pulmonary artery. Our colleague PD Dr. Lahl was able to carry out the ultrasound diagnosis very quickly on the next working day – and then 1 year of self-therapy using Arixtra injections began.
What remains is a post-thrombotic syndrome on the left leg – this can be seen in the video by the clear swelling and the increased occurrence of retinal veins and varicose veins in comparison to the right, healthy leg.
The Covid-19 High Noon: post-thrombotic syndrome!
Post-thrombotic syndrome (PTS) occurs in approximately 20–50% of patients after deep venous thrombosis and has a significant impact on the quality of life of the patients. Even in the case of a Covid-19 infection, post-thrombotic syndrome can occur after venous thrombosis – unless the life-threatening pulmonary embolism occurs beforehand!
In the first place there are swellings and congestion in the lower leg, which increase depending on the temperature in summer. A permanent increase in the circumference of the affected leg is a sure sign. Then there are skin changes, brown discoloration due to the storage of blood and tissue breakdown products, an increase in spider veins and retinal veins, the formation of strong lateral branch and connecting varicose veins. And there is increased skin inflammation, dermatoses and poorly healing wounds. The end point here is the „open leg“.
The treatment options for post-thrombotic syndrome (PTS) of the leg veins are only conservative. Compression, physiotherapy and massages are the possible therapy options, and – the unconditional therapy of the existing varicose veins.
It is important to exploit all of these conservative therapeutic options. Since PTS is rarely life-threatening and limb loss is hardly to be feared, varicose vein surgery should then be performed as little invasively as possible. Therefore, the endovascular techniques (venous glue, radio wave, laser, microfoam) offer themselves as therapy.
A minimally invasive surgical technique is also advisable because the PTS leads to a significant new formation of side branch and connecting varicose veins. Existing varicose veins, regardless of the region, will increase dramatically. This includes enlargement of the venous diameter, recurrent phlebitis (superficial venous thrombosis) and a further functional deterioration. Therapy with the usual radical surgical operations (stripping, lateral pulling) means an increase in surgical complications.
The Covid-19 High Noon: The office hours reality!
Unfortunately, during our consultation we repeatedly meet patients who also talk about thrombosis and pulmonary embolism and who tell us that tablets have been administered and that no varicose or coagulation diagnosis has been carried out. For us, an alarm signal that varicose veins as the cause of these acute diseases may not always be taken seriously.
Regardless of this, it is very important from our point of view when the first contact with varicose and thrombosis patients to always point out the functional component! All the more so since the current Covid-19 epidemic obviously also carries a very high risk of thrombosis.
Saphenion continues to develop office hours options.
Due to the current development and situation, we will expand our specialist work at Saphenion at both locations.
Due to the current development and situation, we will expand our specialist work at Saphenion at both locations.
In addition to the mandatory ultrasound diagnostics of the leg and pelvic veins, and the resulting therapy recommendations, we will also introduce laboratory coagulation diagnostics from Monday April 20th, 2020. We are cooperating in Berlin with the nearby coagulation institute of Prof. Kiesewetter. In Rostock we will take blood samples ourselves and then have the special coagulation parameters examined for a deficiency.
In this way, from our vascular surgery – venotherapy perspective, the possibility is created of being able to better assess possible thrombosis and pulmonary embolism risks under the aspect of the current Covid-19 pandemic.
This results in extended prophylactic and therapeutic recommendations for the affected patients, which are then adapted to the current situation under the „Covid-19 High Noon“ in accordance with the guidelines on thrombosis prophylaxis and therapy.
And we recommend that all colleagues in the practice and clinic have regular thromboprophylaxis for all (!) Covid-19 infected people over the entire period of the infection, regardless of age and gender!
Our first therapy recommendation is an injection therapy with the preparation Arixtra 7.5 mg as a therapeutic dosage. After 14 days – 4 weeks, the switch to another 4 – 8 weeks Arixtra 2.5 mg as a prophylactic dose is advisable. If you already have pulmonary embolism, Arixtra 7.5 mg can be given twice every 12 hours (successful in self-experiment with your own pulmonary embolism).
In the acute phase of thrombosis and embolism, we have seen better clinical and therapeutic results with injection therapy than with thrombosis prophylaxis tablets!
Permanent therapy, including antithrombotic tablets, is strongly recommended for patients with congenital coagulation disorders.
These recommendations should continue to apply until we know the mechanism of thrombosis / embolism formation in COVID-19 and can possibly already counter this prophylactically.
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Telefonisches Gesprächsprotokoll zwischen Prof. Klaus Püschel und Dr. Ulf Th. Zierau vom 23.04.2020 8.00 – 8.25 Uhr.
https://www.aerzteblatt.de/archiv/184621/Therapie-des-postthrombotischen-Syndroms