Deep venous thrombosis: Difference between revisions
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Consider admission for: | Consider admission for: | ||
#Presence of massive DVT | #Presence of massive DVT | ||
##Phlegmasia alba dolens ("painful white edema") - Some venous flow through superficial system | |||
##Phlegmasia cerulea dolens ("painful blue edema") - Complete venous obstruction leads to venous congestion, which impedes arterial inflow | |||
##Venous gangrene - Ultimate dreaded consequence in this spectrum due to ischemia | |||
#Presence of concurrent symptoms of PE | #Presence of concurrent symptoms of PE | ||
#High-risk of anticoagulation-related bleeding | #High-risk of anticoagulation-related bleeding | ||
Revision as of 01:44, 1 January 2014
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 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
- Fracture
- Reflex sympathetic dystrophy
- Lymphangitis
- Buerger's disease
- Arthritis
- Tendonitis
- Myositis
- Arteritis
Disposition
Consider admission for:
- Presence of massive DVT
- Phlegmasia alba dolens ("painful white edema") - Some venous flow through superficial system
- Phlegmasia cerulea dolens ("painful blue edema") - Complete venous obstruction leads to venous congestion, which impedes arterial inflow
- Venous gangrene - Ultimate dreaded consequence in this spectrum due to ischemia
- 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
- Warfarin 5mg PO daily (give 7 days worth only)
- Arrange for 2-3 day follow-up in anticoagulation clinic
- Inpatient
- Warfarin AND
- Enoxaparin: 1 mg/kg SC q12hr OR 1.5mg/kg SC qday OR
- Unfrationated heparin: 80 units/kg bolus; then 18 units/kg/hr
- Check PTT after 6hr; adjust infusion to maintain PTT at 1.5-2.5x control
See Also
Source
Tintinalli
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