DVT Management
To remain aware and stay updated on Deep Vein Thrombosis is as important as drinking water - Anonymous.
HWN Suggests
Options, Approaches to Outpatient Treatment of Deep Vein Thrombosis...
After the diagnosis is established, it should be decided if the patient is appropriate for outpatient management. Those with iliofemoral clot, unstable clot visualized on ultrasound, severe comorbid conditions, or unstable social situations make poor candidates for discharge from the emergency department. There is a paucity of data on outpatient management of upper-extremity DVT. Special attention should be paid to the patient’s risk of bleeding once anticoagulated.
Featured
Outpatient Treatment for DVT… Ready for Primetime?
So, it appears DOACs are safe and efficacious. Xarelto 15 mg twice daily for 21 days, then 20 mg once daily OR Eliquis 10 mg twice daily for 7 days, then 5 mg twice daily. NOACs should be avoided in patients with severe renal or liver disease, those who cannot comply with consistent dosing, recent bleeding and platelets < 70,000/mm3.
DOACs Part 1: Use and Misuse
The first thing to know about DOAC dosing is that dosages are different for venous thromboembolism than for atrial fibrillation. Dosing for venous thromboembolism is fixed as opposed to atrial fibrillation where it is adjusted based on renal function, weight and age. Apixiban 10mg po bid for 1 week followed by 5mg po bid or Rivaroxiban 15mg po bid for 3 weeks followed by 20mg once daily.
Wells' Criteria for DVT
Calculates risk of DVT based on clinical criteria...
EM@3AM: DVT
Most patients with DVT may be discharged home with DOAC or LMWH bridge to warfarin. Patients should be ambulatory, hemodynamically stable, low risk of bleeding, have no renal failure, and be able to follow up within several days. Consider admission for extensive clot (phlegmasia), ileofemoral DVT, high bleeding risk, significant comorbidities, unable to obtain follow up, renal disease (GFR < 30).
How I treat venous thromboembolism in pregnancy
The management of pregnancy-related VTE is based on extrapolation from the nonpregnant population, and clinical trial data on the optimal treatment are scarce... LMWH in therapeutic doses is the treatment of choice during pregnancy, and anticoagulation should be continued until 6 weeks after delivery, for a minimum total duration of 3 months. Whether dosing should be based on weight or anti-Xa level is unknown, and practice differs among centers.
The Approach to Venous Thromboembolism
While the ultrasound does not have any medical risks to the patient, it is expensive and during busy days it can take a lot of time to get done. So instead of instinctively ordering it, Dr. Gore reminds us that there isn’t just a Wells Score for PE, there’s one for DVT too, and we should use it. Once you calculate the score, you’ll have a better idea of the patients risk of DVT:
Articles of Interest
A Swollen Leg
The decision to anticoagulate and what agent to use (including for how long) is a highly individualized decision taking into account the nature and cause of the DVT (clot burden, provoked or not, etc), patient co-morbidities, age, risk of bleeding, social concerns, costs of treatment, patient follow up, as well as patient and physician preferences.
Should I Stay or Should I Go: Outpatient Treatment of Venous Thromboembolism
The care of venous thromboembolism (VTE) is currently undergoing a paradigm shift in the US with an increasingly large percentage of patients being discharged home from the Emergency Department (ED).
Resources
CanadiEM
This episode covers the risk factors, diagnostic approach, treatment and management of PEs and DVTs.
CoreEM
Most patients with DVTs can be discharged home on either oral anticoagulation with a NOAC or with a LMWH bridge to warfarin
International Emergency Medicine Education Project
DVT management does not alter in the elderly. Frequency and severity of DVT increase. Anticoagulation complications are more frequent than younger counterparts. Concomitant diseases and possible drug interactions complicate the management.
Pediatric EM Morsels
The majority of cases of occur in children who have been recently / are hospitalized.
The NNT
Diagnostics and Likelihood Ratios, Explained.
