Deep vein thrombosis resident survival guide: Difference between revisions
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(/* Diagnostic approach{{cite journal| author=Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells PS, Stevenson MD et al.| title=Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence...) |
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*Pregnancy | *Pregnancy | ||
==Diagnostic approach | ==Diagnostic approach== | ||
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{{familytree | | | | | | | | | | | A01 | | | | |A01='''Pretest Probability of DVT'''<br>'''Major points'''<br>1-Active cancer<br> 2-Paralysis,paresis or plastic<br> immobilization of leg or foot <br>3-Recent bed rest >3 days <br>or major surgery in the last 4 weeks or both<br> 4-Calf or thigh swelling 5->3 cm calf swelling<br>below the tibial tuberosity<br> 5-Strong F/H of DVT<br>'''Minor points'''<br>1-H/O recent trauma to the suspected leg<br>2-Pitting edema in the suspected leg<br>3-Dilated superficial veins in the suspected leg<br>4-Hospitalization in the last 6 months<br>5-Erythema }} | {{familytree | | | | | | | | | | | A01 | | | | |A01='''Pretest Probability of DVT'''<br>'''Major points'''<br>1-Active cancer<br> 2-Paralysis,paresis or plastic<br> immobilization of leg or foot <br>3-Recent bed rest >3 days <br>or major surgery in the last 4 weeks or both<br> 4-Calf or thigh swelling 5->3 cm calf swelling<br>below the tibial tuberosity<br> 5-Strong F/H of DVT<br>'''Minor points'''<br>1-H/O recent trauma to the suspected leg<br>2-Pitting edema in the suspected leg<br>3-Dilated superficial veins in the suspected leg<br>4-Hospitalization in the last 6 months<br>5-Erythema }} | ||
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{{Family tree| | | F01 | | F02 | | F03 | | F04 | | | | F05 | | | F06 | | | | |F01=Negative|F02=Positive|F03=Negative|F04=Positive|F05=Negative|F06=Positive}} | {{Family tree| | | F01 | | F02 | | F03 | | F04 | | | | F05 | | | F06 | | | | |F01=Negative|F02=Positive|F03=Negative|F04=Positive|F05=Negative|F06=Positive}} | ||
{{Family tree| | | |!| | | |!| | | |!| | | |!| | | | | |!| | | |,|^|-|.| | |}} | {{Family tree| | | |!| | | |!| | | |!| | | |!| | | | | |!| | | |,|^|-|.| | |}} | ||
{{Family tree| | | G01 | | G02 | | G03 | | G04 | | | | G05 | | G6| | G7| |G01=No DVT|G02=Treat|G03=Repeat in 7 days|G04=Treat|G05=No DVT|G6=Repeat in 7 days|G7=U/S}} | {{Family tree| | | G01 | | G02 | | G03 | | G04 | | | | G05 | | G6| | G7| |G01=No DVT|G02=Treat|G03=Repeat in 7 days|G04=Treat|G05=No DVT|G6=Repeat in 7 days|G7=U/S<ref name="pmid22315267">{{cite journal| author=Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells PS, Stevenson MD et al.| title=Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. |journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e351S-418S | pmid=22315267 | doi=10.1378/chest.11-2299 | pmc=PMC3278048 |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315267 }} </ref>}} | ||
{{familytree/end}} | {{familytree/end}} | ||
Revision as of 18:47, 9 December 2013
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Abdurahman Khalil, M.D. [2]
Definition
Deep vein thrombosis (also known as deep venous thrombosis or DVT and colloquially referred to as economy class syndrome) is the formation of a blood clot ("thrombus") in a deep vein. The risk is significantly increased if the thrombus embolizes to the lungs, causing pulmonary embolism.
Causes
Life Threatening Causes
Common Causes
- Long term immobility
- Clotting disorders
- Cardiac failure
- Hip replacement
- Estrogen in OCP and HRT
- Nephrotic syndrome
- Obesity
- Pregnancy
Diagnostic approach
Pretest Probability of DVT Major points 1-Active cancer 2-Paralysis,paresis or plastic immobilization of leg or foot 3-Recent bed rest >3 days or major surgery in the last 4 weeks or both 4-Calf or thigh swelling 5->3 cm calf swelling below the tibial tuberosity 5-Strong F/H of DVT Minor points 1-H/O recent trauma to the suspected leg 2-Pitting edema in the suspected leg 3-Dilated superficial veins in the suspected leg 4-Hospitalization in the last 6 months 5-Erythema | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Low probability* | Moderate probability* | High probability* | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
D-Dimer | D-Dimer | U/S | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Negative | Positive | Negative | Positive | Negative | Positive | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
No DVT | U/S | No DVT | U/S | Repeat in 7 days | D-Dimer | Treat | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Negative | Positive | Negative | Positive | Negative | Positive | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
No DVT | Treat | Repeat in 7 days | Treat | No DVT | Repeat in 7 days | U/S[1] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
- High probability:
>3 major points+ no alternative diagnosis
or 2 major points + 2 minor points + no alternative diagnosis.
Low probability:
1 major point +≥2 minor + alternative diagnosis
or 1 major + ≥1 minor + no alternative diagnosis
or no major points+ irrespective of minor points +irrespective of diagnosis.
Moderate probability:
neither high or low probability.[2]
Management
DVT confirmed | |||||||||||||||||||||||||||||||
Hemodynamically unstable(massive PE) SBP<90 mm Hg or 40 mm Hg drop Syncope Severe hypoxemia or respiratory distress | Hemodynamically stable | Contraindication for Anticoagulation therapy Absolute Active severe hemorrhage Intracranial hemorrhage Relative Recent surgery, trauma, anemia,GI bleeding, PUD | |||||||||||||||||||||||||||||
Thrombolytic therapy | LMWH or UFH(target INR:2.5, monitor Plt count)+ Warfarin or Fondaparinux | IVC filter | |||||||||||||||||||||||||||||
Do's
- Start vitamin K antagonist no more than 1 or days after start UFH or LMWH.The initial dose for the first 2 days should be 10 mg daily then in accordance to the required INR measurements.
- INR therapeutic ranges are 2.0-3.0 and Target INR is 2.5 and that is applied for patients with hypercoagulable state (antiphospholipid syndrome).
- For IV UFH administration use weight adjusted dose for the initial bolus(80 unit/kg) and the following continuous infusion(18 unit/kg/hr), and for subcutaneous UFH (first dose 333 units/kg, then 250 units/kg).
Don'ts
References
- ↑ Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells PS, Stevenson MD; et al. (2012). "Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e351S–418S. doi:10.1378/chest.11-2299. PMC 3278048. PMID 22315267.
- ↑ Wells PS, Anderson DR, Bormanis J, Guy F, Mitchell M, Gray L; et al. (1997). "Value of assessment of pretest probability of deep-vein thrombosis in clinical management". Lancet. 350 (9094): 1795–8. doi:10.1016/S0140-6736(97)08140-3. PMID 9428249.