- Isolated tibial or peroneal DVTs
- Up to 25% IDDVTs propagate in hospitalized patients, but incidence is lower in ambulatory patients
Only 40% of ambulatory ED patients with PE have concomitant DVT
- Lovenox 30mg SubQ q12 hrs (if Cr Clearance > 30)
- Check AntiXa level every week EXACTLY 4 hours after 3rd dose of lovenox
- prophylactic goal: 0.2-0.6
- therapeutic goal: 0.6-1.2
- Recheck AntiXa level after each 3rd dose if dose is changed until you are at goal
- Recheck level every week (usually qMonday) for all patients
- If renal dysfunction order heparin 5000 Units SubQ q8 hrs (search “SURG DVT/VTE prophylaxis” order set)
- Repeat DVT scan in 2-5 days to look for clot propagation
- May require anticoagulation for 3 months if clot extends proximally
- Case by case basis, with discharge and follow up ultrasound as reasonable option
- Must weight risk of bleeding of anticoagulation with risk of clot propagation
↑ 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.
- Kline JA. Pulmonary Embolism and Deep Vein Thrombosis, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2013, (Ch) 88: p 1157-1170.
- Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ. Chest. 2012;141(2_suppl):7S-47S. doi:10.1378/chest.1412S3.