Deep venous thrombosis: Difference between revisions

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==Diagnosis==
==Diagnosis==
===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%)<ref>Anand SS, et al. Does this patient have deep vein thrombosis? JAMA. 1998; 279(14):1094-9.</ref>
===Modified Wells Score===
===Modified Wells Score===
#Active cancer (<6 mo) - 1pt
#Active cancer (<6 mo) - 1pt

Revision as of 14:02, 2 January 2015

Background

Clinical Spectrum of Venous Thromboembolism

Clinical Spectrum of Venous thromboembolism

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

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

Diagnosis

Physical Exam

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

Modified Wells Score

  1. Active cancer (<6 mo) - 1pt
  2. Paralysis, paresis, or immob of extremity - 1pt
  3. Bedridden >3 d b/c of sx (w/in 4 wk) - 1pt
  4. TTP along deep venous system - 1pt
  5. Entire leg swollen - 1pt
  6. Unilateral calf swelling >3cm below tibial tuberosity - 1pt
  7. Unilateral pitting edema - 1pt
  8. Collateral superficial veins (not varicose) - 1pt
  9. Previously documented DVT - 1pt
  10. Alternative dx 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

Differential Diagnosis

Calf pain

Treatment

Contraindications to anticoagulation

Proximal DVT

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

Distal DVT

  • Symptomatic
  • Asymptomatic with extension of thrombus toward proximal veins
  • Asymptomatic without extension
    • d/c with compressive U/S q2weeks

Therapy

  • Standard anticoagulation regimen
    • Enoxaparin 1 mg/kg q12h 4-5 days
    • Coumadin
      • typical starting dose 5 mg/day
      • give 7d supply with first dose in ED
  • For pts with 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

Disposition

Inpatient therapy for pts 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 pts 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

Source

  • Tintinalli
  • UpToDate
  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.