Difference between revisions of "Deep venous thrombosis"

(Text replacement - "==Diagnosis==" to "==Evaluation==")
(Text replacement - " dx" to " diagnosis")
Line 45: Line 45:
*Collateral superficial veins (not varicose) - 1pt
*Collateral superficial veins (not varicose) - 1pt
*Previously documented DVT - 1pt
*Previously documented DVT - 1pt
*Alternative dx as likely or more likely than DVT - (-)2pts
*Alternative diagnosis as likely or more likely than DVT - (-)2pts
[[File:Deep vein thrombosis of the right leg.jpg|thumbnail|DVT of right leg]]
[[File:Deep vein thrombosis of the right leg.jpg|thumbnail|DVT of right leg]]

Revision as of 12:42, 31 July 2016


Clinical Spectrum of Venous thromboembolism

Only 40% of ambulatory ED patients with PE have concomitant DVT[1][2]


Leg Vein Anatomy

Blausen 0609 LegVeins.png

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

Calf pain


Modified Wells Score

  • Active cancer (<6 mo) - 1pt
  • Paralysis, paresis, or immob of extremity - 1pt
  • Bedridden >3 d b/c of symptoms (within 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 diagnosis as likely or more likely than DVT - (-)2pts
DVT of right leg
Large DVT of left leg


  • 0-1 = Low probability
  • ≥2 = High probability
Low Probability
High Probability

ACEP Clinical Algorithm[4]

DVT clinical algorithm


Therapy Indications

treatment centers around anticoagulation although if signs of ischemia, thrombectomy is also an option Proximal DVT

  • If NO phlegmasia cerulea dolens:
  • If phlegmasia cerulea dolens:
    • Consider thrombolytics +/- thrombectomy
    • Anticoagulate with heparin/coumadin x 3 months
  • If anticoagulation contraindicated:

Distal DVT

  • Symptomatic
  • Asymptomatic with extension of thrombus toward proximal veins
  • Asymptomatic without extension
    • Discharge with compressive U/S q2 weeks

Anticoagulation Options

Coumadin Regimen

  • Standard anticoagulation regimen
    • Enoxaparin 1mg/kg q12h 4-5 days
    • Coumadin
      • typical starting dose 5mg/day
      • give 7d supply with first dose in ED
  • 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

Rivaroxaban (Xarelto) Regimen

  • Standard
    • Start 15mg PO BID x 21 days, then 20mg PO daily (duration depending on risk factors)
    • No need for initial enoxaparin
  • Renal dosing
    • Check creatinine on all patients prior to initiation
    • CrCl <30 avoid use

Contraindications to anticoagulation


Inpatient therapy for patients 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 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


  1. 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.
  2. 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.
  3. Anand SS, et al. Does this patient have deep vein thrombosis? JAMA. 1998; 279(14):1094-9.
  4. Del Rios M et al. Focus on: Emergency Ultrasound For Deep Vein Thrombosis. ACEP News. March 2009. https://www.acep.org/clinical---practice-management/focus-on--emergency-ultrasound-for-deep-vein-thrombosis/.