DVT Flashcards
differentials with DVT ?
cellulitis
if pain not in keeping with physical findings - check for ISCHEMIA
musculoskeletal pain
SUPERFICIAL THROMBOPHLEBITIS
history of DVT ?
SOCRATES
site ?
onset ?
character ?
radiates?
associated ?symptoms
exacerbating and relieving factors ?
time course?
severity ?
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I would ask for risk factors of DVT
such as any
ACTIVE CANCER - treatment ongoing or within previous 6 months
paralysis or recent immbolisation
recently bedridden for more than 3 days or
major surgery in the previous 12 weeks requiring general or regional anaesthesia
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SYSTEMIC SIGNS - fever
any SOB ?
chest pain ?
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family history of thrombotic tendencies
clinical signs of DVT which I would be looking for ?
Localised tenderness along the distribution of the deep venous system: +1
Swelling of the entire leg: +1
Calf swelling of 3 cm or more when compared to the asymptomatic leg: +1
Pitting edema (in the symptomatic leg): +1
COLLATERAL SUPERIFICAL VEINS (non-varicose): +1
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Tenderness and firmness of the calf on palpation
Calf pain on dorsiflexion – known as Homans sign
Discolouration of the peripheral foot
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Spreading erythema, trauma or breakdown of the skin may indicate cellulitis. There may be evidence of oozing or crusting.
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palpable peripheral pulses,
capillary refill time distally
temperature of the foot compared to the other side as part of my work to rule out ischaemic pain of the foot and leg
what investigations would you order
bedside investigations = ECG
fbc , ue , lft , coag , ESR , crp
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use a WELLS 2 SCORE for further investigations
1) 2 points or more DVT likely
US of leg within 4 hours
if result negative - arrange for a d-dimer test
if both negative then alternative diagnosis should be sought
if US cannot be carried out within 4 hours
then D-dimer and interim therapeutic clexane / LMHW or DOAC
scan should be done within 24 hours
if scan negative and d-dimer positive
stop anticoagulation
repeat US in a week
PREFERRED IS APIXABAN OR RIVAROXABAN
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if 1 point or less
perform d-dimer within 4hours
if not within 4hours - interim therapeutic anticoagulant
if d-dimer negativee= alternative diagnosis
d-dimer positive = US scan of leg within 4 hours
if not done within 4 hours interim therapeutic anticoagulation should be continued
and US scan done within 24 hours
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IF THE PATINET HAS ANTIPHOSPHOLIPID SYNDROME WITH TRIPILE POSITIVE - CONSIDER WARFARIN
D- dimer test how should it be used and limitations ?
age adjusted cut off should be used
d-dimer has a very good negative predictive value
however it is not really reliable when it is positive - multipe factors can cause d-dier to be high
in women pregnancy
tumors
infection
length of anticoagulation ?
all patients should have anticoagulation for at least 3 months
if the VTE was provoked the treatment is typically stopped after the initial 3 months
if the VTE was unprovoked then treatment is typically continued for up to 3 further months (i.e. 6 months in total)
how to treat people with DOAC
anticoagulation counselling
with booklet
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 over-the-counter medications on their effects;
making them aware that they should discuss its use with medical professionals before planned procedures or becoming pregnant.
REFER TO ANTICOAGULATION CLINIC FOR FOLLOW UP
WHAT FURTHER INVESTIGATION recommended for patients who have unprovoked DVT ?
a full physical examination for any lumps or prominent lymph nodes
a CTCAP is not usually advised unless there is other clinical findings leading you to suspect cancer
Thrombophilia testing is also not routinely offered, but may be considered in people with unprovoked DVT, if there is a plan to stop long term anticoagulation
breaking BAD NEWS
SPIKES
SITUATION
PERCEPTION
INVITATION - warning shot
give time for them to process the information
knowledge - give information so they can process it in small pieces
empathise
summarise
