Deep venous thrombosis

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Background

Clinical Spectrum of Venous thromboembolism

Only 40% of ambulatory ED patients with PE have concomitant DVT[1][2]

Anatomy

Significant risk of PE:

  • Common femoral vein
  • (Superficial) femoral vein
    • (Superficial) femoral vein is part of the deep system, not the superficial system as the name suggests!
  • Popliteal veins

Clinical Features

Physical Exam

  • Leg swelling with circumference >3cm more than unaffected side
  • Tenderness over calf muscle
  • Homan's sign - pain during dorsiflexion of foot (SN 60-96% and SP 20-72%)[3]

Differential Diagnosis

Calf pain

Evaluation

Modified Wells Score

  • Active cancer (<6 mo) - 1pt
  • Paralysis, paresis, or immob of extremity - 1pt
  • Bedridden >3 d b/c of symptoms (within 4 wk) - 1pt
  • TTP along deep venous system - 1pt
  • Entire leg swollen - 1pt
  • Unilateral calf swelling >3cm below tibial tuberosity - 1pt
  • Unilateral pitting edema - 1pt
  • Collateral superficial veins (not varicose) - 1pt
  • Previously documented DVT - 1pt
  • Alternative diagnosis as likely or more likely than DVT - (-)2pts
DVT of right leg
Large DVT of left leg

Probability

  • 0-1 = Low probability
  • ≥2 = High probability
Low Probability
High Probability

ACEP Clinical Algorithm[4]

ACEP DVT Clinical Algorithm

Management

Therapy Indications

treatment centers around anticoagulation although if signs of ischemia, thrombectomy is also an option Proximal DVT

  • If NO phlegmasia cerulea dolens:
  • If phlegmasia cerulea dolens:
    • Consider thrombolytics +/- thrombectomy
    • Anticoagulate with heparin/coumadin x 3 months
  • If anticoagulation contraindicated:

Distal DVT

  • Symptomatic
  • Asymptomatic with extension of thrombus toward proximal veins
  • Asymptomatic without extension
    • Discharge with compressive U/S q2 weeks

VTE in Pregnancy[5]

  • Therapeutic LMWH or unfractionated heparin anticoagulation dose in:
    • Antepartum outpatient with multiple prior VTEs or any VTE with high-risk thrombophilia until 6 weeks postpartum
    • Postpartum inpatient with prior unprovoked, estrogen-provoked VTE, or low-risk thrombophilia for duration of admission
  • Lower prophylactic anticoagulation dose in:
    • Antepartum outpatient with prior unprovoked, estrogen-provoked VTE, or low-risk thrombophilia until6 weeks postpartum
    • Patients admitted > 72 hrs, not at high risk for bleeding or imminent delivery
    • Resume 12 hours after C-section and removal of epidural / spinal needle in indicated patients
  • Halt anticoagulation if imminent delivery, C-section, epidural / spinal needle

Anticoagulation Options

Coumadin Regimen

  • Standard anticoagulation regimen
    • Enoxaparin 1mg/kg q12h 4-5 days
    • Coumadin
      • typical starting dose 5mg/day
      • give 7d supply with first dose in ED
  • GFR <30 and/or potentially requiring reversal
    • Unfractionated Heparin 80 units/kg bolus then 18 units/kg/hour
      • Check PTT after 6hr; adjust infusion to maintain PTT at 1.5-2.5x control
    • Coumadin as above

Rivaroxaban (Xarelto) Regimen

  • Standard
    • Start 15mg PO BID x 21 days, then 20mg PO daily (duration depending on risk factors)
    • No need for initial enoxaparin
  • Renal dosing
    • Check creatinine on all patients prior to initiation
    • CrCl <30 avoid use

Contraindications to anticoagulation

Disposition

Inpatient therapy for patients with ANY of the following:

  • Iliofemoral DVT
  • Phlegmasia cerulea dolens
  • High risk of bleeding on anticoagulation
  • Significant comorbidities
  • Symptoms of concurrent PE
  • Recent (within 2 weeks) stroke or transient ischemic attack
  • Severe renal dysfunction (GFR < 30)
  • History of heparin sensitivity or Heparin-Induced Thrombocytopenia
  • Weight > 150kg

Outpatient therapy for patients with ALL of the following:

  • Ambulatory
  • Hemodynamically stable
  • Low risk of bleeding in patient
  • Absence of renal failure
  • Able to administer (or have administered) LMWH +/- coumadin with appropriate monitoring

Arrange for 2-3 day follow-up in anticoagulation clinic

See Also

External Links

References

  1. Righini M, Le GG, Aujesky D, et al. Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial. Lancet. 2008; 371(9621):1343-1352.
  2. Daniel KR, Jackson RE, Kline JA. Utility of the lower extremity venous ultrasound in the diagnosis and exclusion of pulmonary embolism in outpatients. Ann Emerg Med. 2000; 35(6):547-554.
  3. Anand SS, et al. Does this patient have deep vein thrombosis? JAMA. 1998; 279(14):1094-9.
  4. Del Rios M et al. Focus on: Emergency Ultrasound For Deep Vein Thrombosis. ACEP News. March 2009. https://www.acep.org/clinical---practice-management/focus-on--emergency-ultrasound-for-deep-vein-thrombosis/.
  5. DʼAlton ME et al. National Partnership for Maternal Safety: Consensus bundle on venous thromboembolism. Obstet Gynecol 2016 Oct; 128:688.