Deep venous thrombosis: Difference between revisions

Revision as of 21:29, 22 May 2011

Diagnosis

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
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

Arterial embolism
Septic joint
Osteomyelitis
Compartment syndrome
Nec fasc
Gout
Neuropathy
Nerve entrapment
Sciatica
Fx
Reflex sympathetic dystrophy
Lymphangitis
Buerger's disease
Arthritis
Tendonitis
Myositis
Arteritis

Disposition

Consider admission for:

Presence of massive DVT (phlegmasia cerulea dolens)
Presence of concurrent symptoms of PE
High-risk of anticoagulation-related bleeding
Recent (within 2 weeks) stroke or transient ischemic attack
Severe renal dysfunction (GFR < 30)
History of heparin sensitivity or heparin-induced thrombocytopenia
Weight > 150kg

Treatment

Outpatient
- Enoxaparin 0.5 mg/kg subcutaneously X1 in ED by RN
- Enoxaparin 0.5 mg/kg subcutaneously X1 in ED by pt
- Coumadin 5 mg po x 1 in ED
- Enoxaparin 1mg/kg sc q12hr x 5 days
- Coumadin 5mg PO daily (give 7 days worth only)
- Arrange for 2-3 day follow-up in anticoagulation clinic
Inpatient
- Enoxaparin 1 mg/kg SC q12hr OR 1.5mg/kg SC qday
- UFH 80 units/kg bolus; then 18 units/kg/hr

Source

Tintinalli

UpToDate

@@ Line 1: / Line 1: @@
 ==Diagnosis==
-==Well's Scoring==
+==Wells Score==
-Clinical characteristics:
+#Active cancer (<6 mo) - 1pt
-# Active cancer (<6 mo) 1
+#Paralysis, paresis, or immob of extremity - 1pt
-# Paralysis, paresis, recent immob 1
+#Bedridden >3 d b/c of sx (w/in 4 wk) - 1pt
-# Recent bedridden >3 days,
+#TTP along deep venous system - 1pt
-# Major surg past <4 weeks 1
+#Entire leg swollen - 1pt
-# TTP deep venous system 1
+#Unilateral calf swelling >3cm below tibial tuberosity - 1pt
-# Entire leg swollen 1
+#Unilateral pitting edema - 1pt
-# calf swelling >3cm measured 10cm below tibial tuberosity 1
+#Collateral superficial veins (not varicose) - 1pt
-# Pitting edema > in affected leg 1
+#Alternative dx as likely or more likely than DVT - (-)2pts
-# Symptomatic leg 1
+===Probability===
-# Collateral superficial veins (not varicose) 1
+*0-1 = Low probability
-# alternative dx as likely or greater than that of dvt -2
+*≥2 = High probability
-===Score===
+====Low Probability====
-*2 or greater = high
+*Send d-dimer
-*1 = low
+**If pos obtain utz
-==Treatment==
+====High Probability====
-#High
+*Send d-dimer AND obtain utz
-##D-dimer and UTZ
+**If both negative done
-###If both negative
+**If utz positive done
-####Alt diagnosis
+**If pos d-dimer but neg UTZ:
-###If pos D-dimer, neg UTZ
+***Repeat utz in 1wk
-####repeat UTZ 1 week
-#Low
-##D-dimer neg
-###Alt diagnosis
-##D-dimer pos
-###need UTZ
-####UTZ neg = alt diagnosis
 ==DDx==
@@ Line 52: / Line 45: @@
 ==Disposition==
-===Outpt Rx (Harbor Protocol)===
+*Consider admission for:
-Outpatient treatment of DVT from the Emergency Department
+#Presence of massive DVT (phlegmasia cerulea dolens)
+#Presence of concurrent symptoms of PE
+#High-risk of anticoagulation-related bleeding
+#Recent (within 2 weeks) stroke or transient ischemic attack
+#Severe renal dysfunction (GFR < 30)
+#History of heparin sensitivity or heparin-induced thrombocytopenia
+#Weight > 150kg
-The goal of this protocol is to decrease unnecessary hospital admissions for selected patients who can be treated for deep venous thrombosis on an outpatient basis with low molecular weight heparin (LMWH) and coumadin.
+==Treatment==
+*Outpatient
+**Enoxaparin 0.5 mg/kg subcutaneously X1 in ED by RN
+**Enoxaparin 0.5 mg/kg subcutaneously X1 in ED by pt
+**Coumadin 5 mg po x 1 in ED
+**Enoxaparin 1mg/kg sc q12hr x 5 days
+**Coumadin 5mg PO daily (give 7 days worth only)
+**Arrange for 2-3 day follow-up in anticoagulation clinic
+*Inpatient
+**Enoxaparin 1 mg/kg SC q12hr OR 1.5mg/kg SC qday
+**UFH 80 units/kg bolus; then 18 units/kg/hr
-#Patient Selection
-##All patients diagnosed with DVT should be considered for potential outpatient management with the following exclusion criteria:
-#Absolute contraindications to outpatient management:
-## Presence of massive DVT (phlegmasia cerulea dolens)
-## Presence of concurrent symptoms of pulmonary embolism (PE)
-## High-risk of anticoagulation-related bleeding
-## Presence of acute co-morbid conditions and other factors that would necessitate hospitalization.
-## Recent (within 2 weeks) stroke or transient ischemic attack
-## Hypertensive emergencies
-## Severe renal dysfunction (creatinine clearance < 30mL/min)
-## History of heparin sensitivity or heparin-induced thrombocytopenia
-## Weight > 150kg
-#Relative contraindications to outpatient management:
-## A history of medical noncompliance
-## A history of substance abuse
-## An inability to pay for LMWH
-## Inability to care for self (or no family, friend or nurse to provide care in outpatient setting)
-## Language barrier
-## Lack of access to a clinic or telephone
-===Emergency Department Treatment and follow-up===
+==Source ==
-Physicians will:
+Tintinalli
-# Explain the diagnosis and treatment to the patient, including
+UpToDate
-## The need to take medication exactly as prescribed
-## The risks of anticoagulation including foods to avoid while taking Coumadin
-## The need to keep follow-up appointments
-## The need to return to the ED immediately for signs or symptoms of PE or worsening leg or arm symptoms
-## Print information for all patients, and ask if the patient has any questions
-### English: http://home.mdconsult.com/das/patient/body/0/43/13766.html
-### Spanish: http://home.mdconsult.com/das/patient/body/0/43/13767.html
-# Write the order for:
-## Lovenox 0.5 mg/kg subcutaneously X 1 by RN
-## Lovenox 0.5 mg/kg subcutaneously X 1 by patient and observed
-## Coumadin 5 mg po x 1
-# Arrange for 2-3 day follow-up in an anticoagulation clinic to check INR
-## See Anticoagulation clinic referral in the follow-up binder for patients who are followed at Harbor-UCLA Medical Center.
-## Give appointment at Z: LB for patients without appointments in HIS.
-# Confirm or arrange for follow-up with a PMD to continue management.
-# Provide referral to home health nurse if the patient is unable to self-inject. This form should be dropped in the box across from scheduled admissions. These referrals are only picked up Monday through Friday!
-# Give a prescription for Lovenox 1mg/kg subcutaneously every 12 hours for 5 days (9 doses) and Coumadin 5mg orally daily (give 7 days worth only).
-# Provide a Treatment Authorization Request (TAR) to justify prescription for MediCal patients. Please read the instructions for filling out the TAR carefully and make your name and number
-Nursing will:
-# Provide verbal instruction on how to administer the LMWH injection.
-# Demonstrate how to administer Lovenox by giving the initial 0.5mg/kg dose of lovenox.
-# Have patients demonstrate self injection giving the second 0.5mg/kg for a total initial dose of 1mg/kg.
-# Documenting the ability to self-inject in the chart, or inform the physician that the patient is unable to self-inject.
-# Administer the first dose of oral Coumadin
-# Provide the usual discharge instructions
-Pharmacy will:
-# Provide Lovenox at the Harbor-UCLA Medical Center discounted rate to patients without insurance. Patients with MediCal should get prescriptions at outside pharmacies.
-# Lovenox can be prescribed by all licensed emergency physicians.
-==Source ==
-/30/06 DONALDSON (adapted from Lampe, Wells [Lancet 12\97])
 [[Category:Cards]]
-[[Category:Heme/Onc]]
 [[Category:Ortho]]