DVT complete diagnostic approach resident survival guide

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.

Characterize the symptoms in the involved extremity: ❑ Swelling ❑ Pain ❑ Erythema ❑ Warmth

Identify if symptoms of pulmonary embolism (PE) are present: ❑ Dyspnea (78–81%) ❑ Pleuritic chest pain (39–56%) ❑ Fainting (22–26%) ❑ Cough (20%) ❑ Substernal chest pain (12%) ❑ Hemoptysis (11%) ❑ Wheezing ❑ Cyanosis (11%) ❑ Fever (7%) ❑ 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 ❑ 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 ❑ 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%) ❑ Tachypnea (70%) ❑ 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

Assess the pretest probability of DVT (Wells score shown below)

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

Assess the pretest probability of DVT (Wells score shown below)

(Click here for the diagnostic approach)

Low pretest probability (Click here for the diagnostic approach)

Moderate pretest probability (Click here for the diagnostic approach)

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

❑ Adjust the dosages according to the aPTT

❑ SC unfractionated heparin

❑ 333 U/kg as bolus, followed by 250 U/kg

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

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

SC-UFH

• 333 U/kg as bolus, followed by 250 U/kg

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

Fondaparinux

• 7.5 mg daily
• 10 mg daily if weight>100 Kg