DVT Flashcards
ddx of dvt ?
If the pain was acute and increasing rapidly in intensity I would be worried about the risk of an ischaemic process. This could also be pain referred from a joint and it would be important to rule out ankle or knee pain
muscle pain including tears and strains or Achilles tendonitis.
hx taking
Site,
Onset,
Character,
whether it Radiates,
any Associated symptoms,
Time course,
Exacerbating and relieving factors and Severity.
This would allow me to focus my differential.
want to ask specifically about any period of immobility – long travel, recent surgery.
I would ask about past medical history specifically about any history of DVT or past or active cancer.
I would also ask about systemic symptoms – feeling hot or cold,
any chest pain or shortness of breath.
Finally I would want to know if there is any family history of DVT or other thrombotic tendencies.
Two-level DVT Wells score
Active cancer (treatment ongoing, within 6 months, or palliative)
1
Paralysis, paresis or recent plaster immobilisation of the lower extremities
1
Recently bedridden for 3 days or more or major surgery within 12 weeks requiring general or regional anaesthesia
1
Localised tenderness along the distribution of the deep venous system
1
Entire leg swollen 1
Calf swelling at least 3 cm larger than asymptomatic side 1
Pitting oedema confined to the symptomatic leg 1
Collateral superficial veins (non-varicose) 1
Previously documented DVT 1
An alternative diagnosis is at least as likely as DVT
If a DVT is ‘likely’ (2 points or more)
a proximal leg vein ultrasound scan should be carried out within 4 hours
if the result is negative a D-dimer test should be arranged.
A negative scan and negative D-dimer makes the diagnosis unlikely and alternative diagnoses should be considered
if a proximal leg vein ultrasound scan cannot be carried out within 4 hours a D-dimer test should be performed and interim therapeutic anticoagulation administered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours)
if the scan is negative but the D-dimer is positive:
stop interim therapeutic anticoagulation
offer a repeat proximal leg vein ultrasound scan 6 to 8 days later
If a DVT is ‘unlikely’ (1 point or less)
perform a D-dimer test
done within 4 hours.
If not, interim therapeutic anticoagulation
if the result is negative then DVT is unlikely
result is positive then a proximal leg vein ultrasound scan within 4 hours
if a proximal leg vein ultrasound scan cannot be carried out within 4 hours interim therapeutic anticoagulation administered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours
clinical signs of DVT ?
Calf pain on dorsiflexion – known as Homans sign
Discolouration of the peripheral foot
Swelling of the affected leg which I would measure against the contralateral leg
Spreading erythema, trauma or breakdown of the skin may indicate cellulitis. There may be evidence of oozing or crusting.
I would check for palpable peripheral pulses,
capillary refill time distally and for the temperature of the foot compared to the other side as part of my work to rule out ischaemic pain of the foot and leg.
patient has DVT treatment ?
apixaban or rivaroxaban
has been counselled,
and would not need to be bridged with any low molecular weight heparin.
If either one of these agents was not suitable or available I would start low molecular weight heparin whilst awaiting advice form a senior colleague.
I would refer her to the local anti-coagulation clinic to carry on her treatment.
The length of the treatment is dependent on the cause of the DVT.
Patients with a clear cause for the DVT can be treated for three months whereas DVT caused by cancer, proximal DVTs or unprovoked DVTs should be continued for longer
Anticoag counseling
The medication is taken each day. The medications tend to have a short half-life and it is important to take the medication at the same time each day. If you miss a dose, you should take the medication as soon as you remember if on the same day, however, you should not take two tablets on the same day.
you should seek medical attention: prolonged nosebleed; bleeding from cuts; blood in your stool/vomit/sputum/urine; spontaneous bruising; persistent headache
DOACs do not interact with alcohol. However, I would advise minimal alcohol intake when taking a DOAC
should be given both verbal and written information on how to use the type of anticoagulation;
the duration of treatment;
possible side effects and how to manage these;
the effects of other medications and OTC medications on their effects;
making them aware that they should discuss its use with medical professionals before planned procedures or becoming pregnant.
Patients should be provided with an anticoagulation booklet and ALERT card that they should be encouraged to keep on their person at all times.
What further investigations may be helpful to investigate an unprovoked DVT?
diagnosed with an unprovoked DVT, who are not known to have cancer, should have their medical history reviewed and baseline blood test results, including full blood count, renal and hepatic function, PT and APTT,
and should be physically examined to rule out any obvious signs of cancer.
CT CAP should not be routinely ordered
SPIKES initiation
before discussing the case to the patient i would discuss this case with my consultant or registrar making sure i have all the relevant facts so i do not set any unrealistic expectations
