Deep venous thrombosis: Difference between revisions
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''treatment centers around anticoagulation although if signs of ischemia, thrombectomy is also an option'' | ''treatment centers around anticoagulation although if signs of ischemia, thrombectomy is also an option'' | ||
'''Proximal DVT''' | '''Proximal DVT''' | ||
* If NO phlegmasia cerulea dolens: | *If NO phlegmasia cerulea dolens: | ||
** Anticoagulate with [[heparin]]/[[coumadin]] x 3 months | **Anticoagulate with [[heparin]]/[[coumadin]] x 3 months | ||
* If phlegmasia cerulea dolens: | *If phlegmasia cerulea dolens: | ||
** Consider thrombolytics +/- thrombectomy | **Consider thrombolytics +/- thrombectomy | ||
** Anticoagulate with [[heparin]]/[[coumadin]] x 3 months | **Anticoagulate with [[heparin]]/[[coumadin]] x 3 months | ||
* If anticoagulation contraindicated: | *If anticoagulation contraindicated: | ||
** [[IVC filter]] | **[[IVC filter]] | ||
'''Distal DVT''' | '''Distal DVT''' | ||
* Symptomatic | *Symptomatic | ||
** Anticoagulate with [[heparin]]/[[coumadin]] x 3 months | **Anticoagulate with [[heparin]]/[[coumadin]] x 3 months | ||
* Asymptomatic with extension of thrombus toward proximal veins | *Asymptomatic with extension of thrombus toward proximal veins | ||
** Anticoagulate with [[heparin]]/[[coumadin]] x 3 months | **Anticoagulate with [[heparin]]/[[coumadin]] x 3 months | ||
* Asymptomatic without extension | *Asymptomatic without extension | ||
**Discharge with compressive U/S q2 weeks | **Discharge with compressive U/S q2 weeks | ||
==Anticoagulation Options== | ==Anticoagulation Options== | ||
===[[Coumadin]] Regimen=== | ===[[Coumadin]] Regimen=== | ||
* Standard anticoagulation regimen | *Standard anticoagulation regimen | ||
**[[Enoxaparin]] 1 mg/kg q12h 4-5 days | **[[Enoxaparin]] 1 mg/kg q12h 4-5 days | ||
**[[Coumadin]] | **[[Coumadin]] | ||
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**[[Unfractionated Heparin]] 80 units/kg bolus then 18 units/kg/hour | **[[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 | ***Check PTT after 6hr; adjust infusion to maintain PTT at 1.5-2.5x control | ||
** [[Coumadin]] as above | **[[Coumadin]] as above | ||
===[[Rivaroxaban]] (Xarelto) Regimen=== | ===[[Rivaroxaban]] (Xarelto) Regimen=== | ||
| Line 106: | Line 106: | ||
===Contraindications to anticoagulation=== | ===Contraindications to anticoagulation=== | ||
* Active hemorrhage | *Active hemorrhage | ||
* Platelets <50 | *Platelets <50 | ||
* History of [[intracerebral hemorrhage]] | *History of [[intracerebral hemorrhage]] | ||
==Disposition== | ==Disposition== | ||
'''Inpatient therapy for patients with ANY of the following:''' | '''Inpatient therapy for patients with ANY of the following:''' | ||
* Iliofemoral DVT | *Iliofemoral DVT | ||
* Phlegmasia cerulea dolens | *Phlegmasia cerulea dolens | ||
* High risk of bleeding on anticoagulation | *High risk of bleeding on anticoagulation | ||
* Significant comorbidities | *Significant comorbidities | ||
* Symptoms of concurrent [[PE]] | *Symptoms of concurrent [[PE]] | ||
* Recent (within 2 weeks) stroke or transient ischemic attack | *Recent (within 2 weeks) stroke or transient ischemic attack | ||
* Severe renal dysfunction (GFR < 30) | *Severe renal dysfunction (GFR < 30) | ||
* History of heparin sensitivity or [[Heparin-Induced Thrombocytopenia]] | *History of heparin sensitivity or [[Heparin-Induced Thrombocytopenia]] | ||
* Weight > 150kg | *Weight > 150kg | ||
'''Outpatient therapy for patients with ALL of the following:''' | '''Outpatient therapy for patients with ALL of the following:''' | ||
* Ambulatory | *Ambulatory | ||
* Hemodynamically stable | *Hemodynamically stable | ||
* Low risk of bleeding in patient | *Low risk of bleeding in patient | ||
* Absence of renal failure | *Absence of renal failure | ||
* Able to administer (or have administered) [[LMWH]] +/- [[coumadin]] with appropriate monitoring | *Able to administer (or have administered) [[LMWH]] +/- [[coumadin]] with appropriate monitoring | ||
Arrange for 2-3 day follow-up in anticoagulation clinic | Arrange for 2-3 day follow-up in anticoagulation clinic | ||
Revision as of 13:30, 4 July 2016
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[1][2]
Anatomy
Leg Vein Anatomy
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%)[3]
Differential Diagnosis
- Arterial thrombosis
- Cellulitis
- 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
Calf pain
- Achilles tendon rupture
- Calcaneal bursitis
- Cellulitis
- Compartment syndrome
- Deep venous thrombosis (DVT)
- Distal leg fractures
- Gastrocnemius strain
- Ruptured popliteal cyst (Bakers cyst)
- Superficial thrombophlebitis
Diagnosis
Modified Wells Score
- Active cancer (<6 mo) - 1pt
- Paralysis, paresis, or immob of extremity - 1pt
- Bedridden >3 d b/c of sx (w/in 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 dx as likely or more likely than DVT - (-)2pts
Probability
- 0-1 = Low probability
- ≥2 = High probability
Low Probability
- Send d-dimer
- If positive, obtain ultrasound
High Probability
- Send d-dimer AND obtain ultrasound
- If both negative = no DVT
- If ultrasound positive = DVT
- If positive d-dimer, but neg ultrasound:
- Repeat ultrasound in 1 week
Treatment
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:
- If anticoagulation contraindicated:
Distal DVT
- Symptomatic
- Asymptomatic with extension of thrombus toward proximal veins
- Asymptomatic without extension
- Discharge with compressive U/S q2 weeks
Anticoagulation Options
Coumadin Regimen
- 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
- 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
- Unfractionated Heparin 80 units/kg bolus then 18 units/kg/hour
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
- Active hemorrhage
- Platelets <50
- History of intracerebral hemorrhage
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
- ↑ 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.
- ↑ 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.
- ↑ Anand SS, et al. Does this patient have deep vein thrombosis? JAMA. 1998; 279(14):1094-9.