Difference between revisions of "Deep venous thrombosis"

(Background)
(Evaluation)
Line 36: Line 36:
  
 
==Evaluation==
 
==Evaluation==
===Modified Wells Score===
+
Evaluation can take place with a multitude of decision instruments or by simply using clinical judgment. 
*Active cancer (<6 mo) - 1pt
+
===[[Modified Wells Score]]===
*Paralysis, paresis, or immob of extremity - 1pt
+
{{Modified Wells Score}}
*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
 
  
 
[[File:Deep vein thrombosis of the right leg.jpg|thumbnail|DVT of right leg]]
 
[[File:Deep vein thrombosis of the right leg.jpg|thumbnail|DVT of right leg]]
 
[[File:DVT.jpeg|thumbnail|Large DVT of left leg]]
 
[[File:DVT.jpeg|thumbnail|Large DVT of left leg]]
  
====Probability====
+
====ACEP Clinical Algorithm====
*0-1 = Low probability
+
{{ACEP DVT workup}}
*≥2 = High probability
 
  
=====Low Probability=====
 
*Send d-dimer
 
**If positive, obtain [[DVT ultrasound|ultrasound]]
 
 
=====High Probability=====
 
*Send d-dimer AND obtain [[DVT ultrasound|ultrasound]]
 
**If both negative = no DVT
 
**If [[DVT ultrasound|ultrasound]] positive = DVT
 
**If positive d-dimer, but neg [[DVT ultrasound|ultrasound]]:
 
***Repeat [[DVT ultrasound|ultrasound]] in 1 week
 
 
====ACEP Clinical Algorithm<ref>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/.</ref>====
 
 
[[File:DVT-clinical-algorithm.jpg|thumbnail|ACEP DVT Clinical Algorithm]]
 
[[File:DVT-clinical-algorithm.jpg|thumbnail|ACEP DVT Clinical Algorithm]]
  

Revision as of 16:16, 27 January 2017

Background

Patients with superficial venous thromboses such as the long saphenous, short saphenous and dorsal venous arch increases the risk of developing a DVT, especially in patients who have a history of prior DVT.[1]

Clinical Spectrum of Venous thromboembolism

Only 40% of ambulatory ED patients with PE have concomitant DVT[2][3]

Anatomy

Leg Vein Anatomy

Blausen 0609 LegVeins.png

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%)[4]

Differential Diagnosis

Calf pain

Evaluation

Evaluation can take place with a multitude of decision instruments or by simply using clinical judgment.

Modified Wells Score

Modified Wells Score

Can be applied for patients whose clinical presentation is concerning for a DVT in order to risk stratify.

  • Active cancer (<6 mo) (1pt)
  • Paralysis, paresis, or immobility of extremity (1pt)
  • Bedridden >3 days because of symptoms within 4 weeks (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)

Scoring:

  • A score of 0 or lower → minimal risk - DVT prevalence of 5%. D-dimer testing is safe in this group - negative d-dimer decreases the probability of disease to <1% allowing an ultrasound to be deferred.
  • A score of 1-2 → moderate risk - DVT prevalence of 17%. D-dimer testing still effective and a negative test decreases post-test probability disease to <1%
  • A score of 3 or higher → high risk - DVT prevalence of 17-53% → patients should receive an ultrasound[5]
DVT of right leg
Large DVT of left leg

ACEP Clinical Algorithm

Template:ACEP DVT workup

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[6]

  • 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. Litzendorf ME. Satiani B. Superficial Venous thrombosis:disease progression and evolving treatment approaches. Vasc Health Risk Manag. 2011(7). 569-575
  2. 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.
  3. 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.
  4. Anand SS, et al. Does this patient have deep vein thrombosis? JAMA. 1998; 279(14):1094-9.
  5. 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/
  6. DʼAlton ME et al. National Partnership for Maternal Safety: Consensus bundle on venous thromboembolism. Obstet Gynecol 2016 Oct; 128:688.