Deep venous thrombosis

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

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

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. Fracture
11. Reflex Sympathetic Dystrophy
12. Lymphangitis
13. Buerger's disease
14. Arthritis
15. Tendonitis
16. Myositis
17. Arteritis
18. Paget-Schroetter Syndrome

Treatment

Contraindications to A/C

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

Proximal

• 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

• 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 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

• Ultrasound: DVT
• Paget-Schroetter Syndrome

External Links

• MDCalc - Wells' Criteria for DVT

Source

Tintinalli

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