Deep venous thrombosis

Background

Clinical Spectrum of Venous thromboembolism

• Deep venous thrombosis (uncomplicated)
• Phlegmasia alba dolens
• Phlegmasia cerulea dolens
• Venous gangrene
• Pulmonary embolism
• Isolated distal deep venous thrombosis

Only 40% of ambulatory ED patients with PE have concomitant DVT

Diagnosis

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

• Send d-dimer
  • If pos obtain utz

High Probability

• Send d-dimer AND obtain utz
  • If both negative done
  • If utz positive done
  • If pos d-dimer but neg UTZ:
    • Repeat utz in 1wk

Differential Diagnosis

• Arterial embolism
• Septic Joint
• Osteomyelitis
• Compartment Syndrome
• Nec fasc
• Gout
• Neuropathy
• Nerve entrapment
• Sciatica
• Fracture
• Reflex Sympathetic Dystrophy
• Lymphangitis
• Buerger's disease
• Arthritis
• Tendonitis
• Myositis
• Arteritis
• Paget-Schroetter Syndrome

Treatment

Contraindications to A/C

• Active hemorrhage
• Plt < 50
• h/o intracerebral hemorrhage

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 A/C contraindicated:
  • IVC filter

Distal DVT

• Symptomatic
  • Anticoagulate with heparin/coumadin x 3 months
• Asymptomatic with extension of thrombus toward proximal veins
  • Anticoagulate with heparin/coumadin x 3 months
• 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 A/C
• 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

• Ultrasound: DVT
• Paget-Schroetter Syndrome

External Links

• MDCalc - Wells' Criteria for DVT

Source

• Tintinalli
• UpToDate