Deep venous thrombosis

Well's Scoring

Clinical characteristics:

1. Active cancer (<6 mo) 1
2. Paralysis, paresis, recent immob 1
3. Recent bedridden >3 days,
4. Major surg past <4 weeks 1
5. TTP deep venous system 1
6. Entire leg swollen 1
7. calf swelling >3cm measured 10cm below tibial tuberosity 1
8. Pitting edema > in affected leg 1
9. Symptomatic leg 1
10. Collateral superficial veins (not varicose) 1
11. alternative dx as likely or greater than that of dvt -2

SCORE

2 or greater = high 1 = low

Treatment

1. High
   1. D dimer and UTZ
      1. If both negative, done
      2. If pos D dimer, neg UTZ
         1. repeat UTZ 1 week
2. Low
   1. D dimer neg
      1. done
   2. D dimer pos
      1. need UTZ
         1. UTZ neg done

DDx

1. Arterial embolism
2. Septic joint
3. Osteomyelitis
4. Compartment syndrome
5. Nec fasc
6. Gout
7. Neuropathy
8. Nerve entrapment
9. Sciatica
10. Fx
11. Reflex sympathetic dystrophy
12. Lymphangitis
13. Buerger's disease
14. Arthritis
15. Tendonitis
16. Myositis
17. Arteritis

Disposition

Outpt Rx (Harbor Protocol)

Outpatient treatment of DVT from the Emergency Department

The goal of this protocol is to decrease unnecessary hospital admissions for selected patients who can be treated for deep venous thrombosis on an outpatient basis with low molecular weight heparin (LMWH) and coumadin.

1. Patient Selection
   1. All patients diagnosed with DVT should be considered for potential outpatient management with the following exclusion criteria:
2. Absolute contraindications to outpatient management:
   1. Presence of massive DVT (phlegmasia cerulea dolens)
   2. Presence of concurrent symptoms of pulmonary embolism (PE)
   3. High-risk of anticoagulation-related bleeding
   4. Presence of acute co-morbid conditions and other factors that would necessitate hospitalization.
   5. Recent (within 2 weeks) stroke or transient ischemic attack
   6. Hypertensive emergencies
   7. Severe renal dysfunction (creatinine clearance < 30mL/min)
   8. History of heparin sensitivity or heparin-induced thrombocytopenia
   9. Weight > 150kg
3. Relative contraindications to outpatient management:
   1. A history of medical noncompliance
   2. A history of substance abuse
   3. An inability to pay for LMWH
   4. Inability to care for self (or no family, friend or nurse to provide care in outpatient setting)
   5. Language barrier
   6. Lack of access to a clinic or telephone

Emergency Department Treatment and follow-up

Physicians will:

1. Explain the diagnosis and treatment to the patient, including
   1. The need to take medication exactly as prescribed
   2. The risks of anticoagulation including foods to avoid while taking Coumadin
   3. The need to keep follow-up appointments
   4. The need to return to the ED immediately for signs or symptoms of PE or worsening leg or arm symptoms
   5. Print information for all patients, and ask if the patient has any questions
      1. English: http://home.mdconsult.com/das/patient/body/0/43/13766.html
      2. Spanish: http://home.mdconsult.com/das/patient/body/0/43/13767.html
2. Write the order for:
   1. Lovenox 0.5 mg/kg subcutaneously X 1 by RN
   2. Lovenox 0.5 mg/kg subcutaneously X 1 by patient and observed
   3. Coumadin 5 mg po x 1
3. Arrange for 2-3 day follow-up in an anticoagulation clinic to check INR
   1. See Anticoagulation clinic referral in the follow-up binder for patients who are followed at Harbor-UCLA Medical Center.
   2. Give appointment at Z: LB for patients without appointments in HIS.
4. Confirm or arrange for follow-up with a PMD to continue management.
5. Provide referral to home health nurse if the patient is unable to self-inject. This form should be dropped in the box across from scheduled admissions. These referrals are only picked up Monday through Friday!
6. Give a prescription for Lovenox 1mg/kg subcutaneously every 12 hours for 5 days (9 doses) and Coumadin 5mg orally daily (give 7 days worth only).
7. Provide a Treatment Authorization Request (TAR) to justify prescription for MediCal patients. Please read the instructions for filling out the TAR carefully and make your name and number

Nursing will:

1. Provide verbal instruction on how to administer the LMWH injection.
2. Demonstrate how to administer Lovenox by giving the initial 0.5mg/kg dose of lovenox.
3. Have patients demonstrate self injection giving the second 0.5mg/kg for a total initial dose of 1mg/kg.
4. Documenting the ability to self-inject in the chart, or inform the physician that the patient is unable to self-inject.
5. Administer the first dose of oral Coumadin
6. Provide the usual discharge instructions

Pharmacy will:

1. Provide Lovenox at the Harbor-UCLA Medical Center discounted rate to patients without insurance. Patients with MediCal should get prescriptions at outside pharmacies.
2. Lovenox can be prescribed by all licensed emergency physicians.

Source

1/30/06 DONALDSON (adapted from Lampe, Wells [Lancet 12\97])