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

Disposition

Consider admission for:

1. Presence of massive DVT
   1. Phlegmasia alba dolens ("painful white edema")
      1. Some venous flow through superficial system
      2. Seen in pregnant women
   2. Phlegmasia cerulea dolens ("painful blue edema")
      1. Complete venous obstruction leads to venous congestion, which impedes arterial flow
   3. Venous gangrene
      1. Ultimate dreaded consequence in this spectrum due to ischemia
2. Presence of concurrent symptoms of PE
3. High-risk of anticoagulation-related bleeding
4. Recent (within 2 weeks) stroke or transient ischemic attack
5. Severe renal dysfunction (GFR < 30)
6. History of heparin sensitivity or Heparin-Induced Thrombocytopenia
7. 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
  • Unfractionated 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

• Ultrasound: DVT
• Paget-Schroetter Syndrome

Source

Tintinalli

UpToDate