Deep venous thrombosis: Difference between revisions
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Line 52: | Line 52: | ||
* Plt < 50 | * Plt < 50 | ||
* h/o intracerebral hemorrhage | * h/o intracerebral hemorrhage | ||
'''Proximal''' | '''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 | ||
Line 60: | Line 60: | ||
* If A/C contraindicated: | * If A/C contraindicated: | ||
** IVC filter | ** IVC filter | ||
'''Distal''' | '''Distal DVT''' | ||
* Symptomatic | * Symptomatic | ||
** Anticoagulate with heparin/coumadin x 3 months | ** Anticoagulate with heparin/coumadin x 3 months |
Revision as of 19:06, 26 October 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
- Paget-Schroetter Syndrome
Treatment
Contraindications to A/C
- Active hemorrhage
- Plt < 50
- h/o intracerebral hemorrhage
Proximal DVT
- 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 DVT
- 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
- Unfractionated Heparin 80 units/kg bolus then 18 units/kg/hour
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
External Links
Source
Tintinalli
UpToDate