Phlegmasia cerulea dolens: Difference between revisions

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==Background==
==Background==
* "Painful Blue Leg"
*"Painful Blue Leg"
* Massive iliofemoral occlusion
*Massive iliofemoral occlusion due to venous thromboembolism
* Extensive vascular congestion and venous ischemia
*Extensive vascular congestion and venous ischemia


===Risk Factors===
===Risk Factors===
* Age 50-60s
*Age 50-60s
* Malignancy (20-40%)
*Malignancy (20-40%)
* Idiopathic (10%)
*Inherited thrombophilia
* Inherited thrombophilia
*Pregnancy
* Pregnancy
*Trauma/surgery
* Trauma/surgery
*Immobilization
* IVC filter
*IVC filter
*10% of cases are idiopathic and occur in patients without risk factors


==Clinical Features==
==Clinical Features==
* Sudden severe leg pain
[[File:PCD2016.jpg|thumb|Two hour history of phlegmasia cerulea dolens (left leg)]]
* Swelling and edema (bleb/bullae)
[[File:PMC5198769 vsi-32-201f1.png|thumb|At presentation (A) and post-op day 1 (B).]]
* Cyanosis
*Sudden severe leg pain
* Venous gangrene
*Swelling and edema (bleb/bullae)
* [[Compartment syndrome]]
*Cyanosis
* Arterial compromise
*Venous gangrene
* Shock
*[[Compartment syndrome]]
* Often preceded by [[phlegmasia alba dolens]]
*Arterial compromise
*[[Shock]]
*Often preceded by [[phlegmasia alba dolens]]


==Differential Diagnosis==
==Differential Diagnosis==
{{Venous thromboembolism types}}
{{Venous thromboembolism types}}


* [[Cellulitis]]
*[[Cellulitis]]
* [[Lymphedema]]
*[[Lymphedema]]
* [[Venous valvular insufficiency]]
*[[Venous valvular insufficiency]]
* [[Superficial thrombophlebitis]]
*[[Superficial thrombophlebitis]]


==Diagnosis==
==Evaluation==
* Clinical diagnosis
*Clinical diagnosis
* Duplex US
*Duplex US
* Contrast venography
*Contrast venography


==Management==
==Management==
* For mild, non-gangrenous form: Conservative management
*For mild, non-gangrenous form: Conservative management
** Steep limb elevation
**Steep limb elevation
** Fluid resuscitation
**Fluid resuscitation
** Heparin: 80-100U/kg followed by infusion of 15-18U/kg/hr
**[[Heparin]]: 80-100U/kg followed by infusion of 15-18U/kg/hr
* Vascular surgery consult for emergent thrombectomy
*Vascular surgery consult for emergent thrombectomy
* Interventional radiology consult for emergent catheter-directed thrombolysis
*Interventional radiology consult for emergent catheter-directed thrombolysis
* Thrombolytic therapy
**[[Thrombolytic]] therapy: [[Alteplase]] (1mg/min to total of 50mg) distal to thrombus
**Alteplase (1mg/min to total of 50mg) distal to thrombus


==Disposition==
==Disposition==
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==External Links==
==External Links==


==Sources==
==References==
<references/>
<references/>
*Rosen's Emergency Medicine 8th edition. 2013. Chapter: Pulmonary Embolism and Deep Vein Thrombosis p. 1159.
*Rosen's Emergency Medicine 8th edition. 2013. Chapter: Pulmonary Embolism and Deep Vein Thrombosis p. 1159.
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*Lip GY, et al. Overview of the treatment of lower extremity deep vein thrombosis (DVT). In: Post T, ed. UpToDate. Waltham, Mass.: UpToDate; 2014. www.uptodate.com. Accessed December 21, 2014.
*Lip GY, et al. Overview of the treatment of lower extremity deep vein thrombosis (DVT). In: Post T, ed. UpToDate. Waltham, Mass.: UpToDate; 2014. www.uptodate.com. Accessed December 21, 2014.


[[Category:Cards]]
[[Category:Cardiology]]
[[Category:Ortho]]
[[Category:Orthopedics]]
[[Category:Vascular]]

Revision as of 04:03, 2 April 2019

Background

  • "Painful Blue Leg"
  • Massive iliofemoral occlusion due to venous thromboembolism
  • Extensive vascular congestion and venous ischemia

Risk Factors

  • Age 50-60s
  • Malignancy (20-40%)
  • Inherited thrombophilia
  • Pregnancy
  • Trauma/surgery
  • Immobilization
  • IVC filter
  • 10% of cases are idiopathic and occur in patients without risk factors

Clinical Features

Two hour history of phlegmasia cerulea dolens (left leg)
At presentation (A) and post-op day 1 (B).

Differential Diagnosis

Clinical Spectrum of Venous thromboembolism

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

Evaluation

  • Clinical diagnosis
  • Duplex US
  • Contrast venography

Management

  • For mild, non-gangrenous form: Conservative management
    • Steep limb elevation
    • Fluid resuscitation
    • Heparin: 80-100U/kg followed by infusion of 15-18U/kg/hr
  • Vascular surgery consult for emergent thrombectomy
  • Interventional radiology consult for emergent catheter-directed thrombolysis

Disposition

  • Admit

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.
  • Rosen's Emergency Medicine 8th edition. 2013. Chapter: Pulmonary Embolism and Deep Vein Thrombosis p. 1159.
  • Dardik A. (2014, Feb 25). Phlegmasia Alba and Cerulea Dolens. eMedicine. Retrieved 12/21/2014 from http://emedicine.medscape.com/article/461809-overview.
  • Lip GY, et al. Overview of the treatment of lower extremity deep vein thrombosis (DVT). In: Post T, ed. UpToDate. Waltham, Mass.: UpToDate; 2014. www.uptodate.com. Accessed December 21, 2014.