Deep venous thrombosis: Difference between revisions
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==Treatment== | ==Treatment== | ||
===Therapy Indications=== | |||
'''Proximal DVT''' | '''Proximal DVT''' | ||
* If NO phlegmasia cerulea dolens: | * If NO phlegmasia cerulea dolens: | ||
| Line 85: | Line 82: | ||
* Asymptomatic without extension | * Asymptomatic without extension | ||
** d/c with compressive U/S q2weeks | ** d/c with compressive U/S q2weeks | ||
''' | '''Contraindications to anticoagulation''' | ||
* Active hemorrhage | |||
* Plt < 50 | |||
* h/o [[intracerebral hemorrhage]] | |||
===Therapy Options=== | |||
* Standard anticoagulation regimen | * Standard anticoagulation regimen | ||
**[[Enoxaparin]] 1 mg/kg q12h 4-5 days | **[[Enoxaparin]] 1 mg/kg q12h 4-5 days | ||
Revision as of 16:13, 23 March 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
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 anticoagulation contraindicated:
- IVC filter
Distal DVT
- Symptomatic
- Asymptomatic with extension of thrombus toward proximal veins
- Asymptomatic without extension
- d/c with compressive U/S q2weeks
Contraindications to anticoagulation
- Active hemorrhage
- Plt < 50
- h/o intracerebral hemorrhage
Therapy Options
- 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 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 pts 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.