DVT complete diagnostic approach resident survival guide

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Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[1]

 
 
 
 
 
 
Characterize the symptoms in the involved extremity:

Swelling
Pain
Erythema

❑ Warmth
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Identify if symptoms of pulmonary embolism (PE) are present:

Dyspnea (78–81%)[2]
Pleuritic chest pain (39–56%)[2]
Fainting (22–26%)[2]
Cough (20%)[3]
Substernal chest pain (12%)[3]
Hemoptysis (11%)[3]
Wheezing
Cyanosis (11%)[2]
Fever (7%)[2]
❑ Symptoms suggestive of shock (in case of massive PE)

Altered mental status
Cold extremities
Cyanosis
Oliguria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Identify possible precipitating factors:
❑ Recent surgery
Hospitalization
Trauma
Pregnancy
Postpartum
Heart failure
❑ Immobility
❑ Recent bed rest
❑ Recent cast of lower extremities
Obesity
❑ Active malignancy
❑ Treatment for malignancy within the last 6 months
Stroke
❑ Paralysis
❑ Paresis
Oral contraceptive or hormone replacement therapy


Elicit a detailed history:

Risk factors[4][3]

Chemotherapy
Chronic heart failure
Respiratory failure
Hormone replacement therapy
Cancer
Oral contraceptive pills
Stroke
Pregnancy
Postpartum
❑ Prior history of VTE
Thrombophilia
❑ Advanced age
Laparoscopic surgery
❑ Prepartum
Obesity
Varicose veins

Triggers[4][3]

Bone fracture (hip or leg)
Hip replacement surgery
❑ Knee replacement surgery
Major general surgery
Significant trauma
Spinal cord injury
❑ Athroscopic knee surgery
Central venous lines
Chemotherapy
❑ Bed rest for more than 3 days
❑ Prolonged car or air travel
Laparoscopic surgery
❑ Prepartum

Previous episode of VTE

❑ Age
❑ Location

Past medical history of diseases associated with hyperviscosity

Atherosclerosis
Collagen vascular disease
Heart failure
Myeloproliferative disease
Nephrotic syndrome
Autoimmune diseases
Polycythemia vera
Hyperhomocysteinemia
Paroxysmal nocturnal hemoglobinuria
Waldenstrom macroglobulinemia
Multiple myeloma

History of thrombophilia

Factor V Leiden mutation
Prothrombin gene mutation G20210A
Protein C or Protein S deficiency
Antithrombin (AT) deficiency
Antiphospholipid syndrome (APS)

Abortion

Abortion at second or third trimester of pregnancy (suggestive of an inherited thrombophilia or APS)

Drugs that may increase the risk of VTE

Hydralazine
Phenothiazine
Procainamide
Tamoxifen
Bevacizumab
Glucocorticoids

Family history (suggestive of inherited thrombophilia)

Deep vein thrombosis
Pulmonary embolism
❑ Recurrent miscarriage

Social history

❑ Heavy cigarette smoking (>25 cigarettes per day)
Intravenous drug use (if injected directly in femoral vein)
Alcohol
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

Vitals
❑ Temperature, blood pressure, heart rate and respiratory rate may all be within normal range in DVT.
❑ Among patients with DVT complicated by PE, the following might be present:

Blood pressure lower than baseline, suggestive of cardiogenic shock (associated with tachycardia and end organ hypoperfusion)
Tachycardia (26%)[3]
Tachypnea (70%)[3]
Low grade fever


Extremities
❑ Unilateral calf or thigh tenderness
❑ Unilateral calf or thigh pitting edema
❑ Unilateral calf or thigh swelling
❑ Difference in calf diameters > 3 cm (the calf circumference is measured 10 cm below the tibial tuberosity)
❑ Difference in thigh diameters (the thigh circumference is measured 10-15 cm above the patella)
❑ Unilateral calf or thigh warmth
❑ Unilateral calf or thigh erythema
❑ Palpable cord (a thickened palpable vein suggestive of thrombosed vein)
❑ Dilatation of unilateral collateral superficial veins
❑ Localized tenderness upon palpation of the deep veins

❑ Posterior calf
❑ Popliteal fossa
❑ Inner anterior thigh

Homan's sign: tenderness upon dorsiflexion of the foot (not reliable)


Skin
❑ Generalized edema (suggestive of right heart failure, or nephrotic syndrome)
Cyanotic and cold skin, lips, nail bed (suggestive of cardiogenic shock)


Abdomen
Ascites (suggestive of Budd Chiari syndrome, that is hepatic vein thrombosis)
Hepatomegaly (suggestive of Budd Chiari syndrome, that is hepatic vein thrombosis)


Heart
Among patients with DVT complicated by PE, the following might be present:
Cardiac murmur

Graham-Steell murmur (suggestive of pulmonary regurgitation)

Accentuated P2
S3 or S4 gallop (suggestive of RV dysfunction)
Jugular venous distention (suggestive of right heart failure)


Lungs
Among patients with DVT complicated by PE, the following might be present:
Rales
Crackles

Pleural friction rub
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider alternative diagnoses:

Muscle strain or muscle tear
Immobilization that led to leg swelling
Lymphedema
Lymphangitis
Chronic venous insufficiency
❑ Venous obstruction ❑ Baker's cyst
Cellulitis
Superficial thrombophlebitis
Hypoproteinemia

Nephrotic syndrome
Cirrhosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order tests:

CBC-D
PT and aPTT
Creatinine

Liver function test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the suspected DVT a first or a recurrent episode?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
First suspected episode
 
Suspected recurrent episode
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low pretest probability
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Moderate pretest probability
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High pretest probability
(Click here for the diagnostic approach)
 
 
 

Initial Anticoagulation Choices (DVT)

❑ SC low molecular weight heparin (1st line)

❑ Enoxaparin 1.0 mg/kg every 12 hours OR 1.5 mg/kg once daily
❑ Tinzaparin 175 U/kg once daily

❑ SC fondaparinux (1st line)

❑ 5 mg once daily (if body weight <50 kg)
❑ 7.5 mg once daily (if body weight <50-100 kg)
❑ 10 mg once daily (if body weight >100 kg)

❑ IV unfractionated heparin

❑ 80 U/kg as bolus, followed by 18 U/kg/h, OR
❑ 70 U/kg as bolus, followed by 15 U/kg/h for stroke or cardiac patients[5]
❑ Adjust the dosages according to the aPTT

❑ SC unfractionated heparin

❑ 333 U/kg as bolus, followed by 250 U/kg[5]

Anticoagulation for VTE

Warfarin

  • Begin with 10 mg warfarin for 2 days followed by dosing based on the INR
  • Start at the 1st or 2nd day of the initial parenteral therapy
  • Target INR is 2-3
  • Monitor INR:
    • If stable, repeat INR every 12 weeks
    • If stable but one value 0.5 below or above the target range, continue the same dose and repeat INR within 1-2 weeks
  • Avoid NSAIDs, COX2 selective NSAIDs and some antibiotics[5]

Heparin

IV-UFH

  • 80 U/kg as bolus, followed by 18 U/kg/h
  • 70 U/kg as bolus, followed by 15 U/kg/h for stroke or cardiac patients[5]

SC-UFH

  • 333 U/kg as bolus, followed by 250 U/kg[5]

LMWH: decrease dose in renal insufficiency (Creatinine clearance < 30 mL/min)[5]

Fondaparinux

  • 7.5 mg daily
  • 10 mg daily if weight>100 Kg[5]
  1. 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.
  2. 2.0 2.1 2.2 2.3 2.4 Cohen AT, Dobromirski M, Gurwith MM (2014). "Managing pulmonary embolism from presentation to extended treatment". Thromb Res. 133 (2): 139–48. doi:10.1016/j.thromres.2013.09.040. PMID 24182642.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P; et al. (2008). "Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". Eur Heart J. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870.
  4. 4.0 4.1 Anderson FA, Spencer FA (2003). "Risk factors for venous thromboembolism". Circulation. 107 (23 Suppl 1): I9–16. doi:10.1161/01.CIR.0000078469.07362.E6. PMID 12814980.
  5. 5.0 5.1 5.2 5.3 5.4 5.5 5.6 Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ; et al. (2012). "Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e152S–84S. doi:10.1378/chest.11-2295. PMC 3278055. PMID 22315259.