DVT
Well's scoring / criteria
Present |
Score |
| Lower limb trauma or surgery or immobilisation in a plaster cast | +1 |
| Bed ridden for more than three days or surgery within the last four week | +1 |
| Tenderness along line of femoral or popliteal veins (NOT just calf tenderness) | +1 |
| Entire limb swollen | +1 |
| Calf more than 3cm bigger circumference, 10cm below tibial tuberosity | +1 |
| Pitting oedema | +1 |
| Dilated collateral superficial veins (on-varicose) | +1 |
| Past Hx of confirmed DVT | +1 |
| Malignancy (including treatment up to six months previously) | +1 |
| Intravenous drug use | +3 |
| Alternative diagnosis is more likely than DVT | -2 |
Pre-test Clinical probability of a DVT with score: DVT "Likely" if Well's > 1, DVT "Unlikely" if Wells< 2
Investigation ? DVT
NOT suitable for home treatment
- Extensive DVT (into iliac veins)
- Unable to walk or in severe pain
- Patient is frail, unsteady on their feet
- Unable to understand the instructions
- Unable to understand the importance of compliance with the treatment
- Unable to return for the scan next morning
- If awaiting scan
- Bleeding risk
- liver disease, active peptic ulcer, alcohol abuse
- Symptoms suggest a PE
Cautions and Contraindications to Innohep or discharge
- Very similar to standard heparin - See eBNF
Must be given sub. cut. NOT i.m.
Contraindications - if any please discuss with consultant
- Recent cerebral haemorrhage, neurosurgery/eye/ear surgery
- Known hypersensitivity to Innohep
- Uncontrolled severe hypertension
- Active peptic ulceration
- Thrombocytopenia
Cautions - if any please discuss case with consultant
- Reduce +dose in renal impairment
- If Innohep® use usual dose if creat cl >20ml/min
- Liver impairment
- Septic endocarditis
- Pregnancy been assessed and no harmful effects are know
Screening
Thrombophilia screen
Considered in those
- Patients with a known Fhx of thrombophilia
- Under 45 years old with VTE, no ppt cause
- Recurrent thromboses
- Thrombosis in an unusual site,
- FHx of thrombosis or
- FHx of recurrent (2 or more) VTE
- Past Hx of of recurrent foetal loss
Request
- Antithrombin
- Protein S, Protein C
- APC resistance
- Factor V Leiden mutation
- Lupus anticoagulant
- Anticardiolipin antibodies
Thrombophilia testing is very expensive and a full screen may cost in excess of 200 euro – use resources judiciously!
British Journal of Haematology 2010: 149 (2) 209-220 Clinical guidelines for testing for heritable thrombophilia (www.bcshguidelines.com)
Patients with proven DVT are at increased risk of occult malignancy.
Once a DVT is diagnosed, please complete
- A thorough physical examination, including breast, pelvic and rectal examination.
- Check FBC, ESR, LFT, U&E, CXR, urinalysis.
- An age-appropriate cancer screening is considered.
- Men > 40 yo - request PSA
- Younger women (no clear cause for DVT) request an outpatient pelvic ultrasound
Links
- Local copy Well's Article Ix DVT NEJM Sept 2003
- Patients who are undergoing orthopaedic treatment who present to the ED with "? DVTs" will be seen and treated by our orthopaedic colleagues. They will then refer on to the medical team if necessary. (letter Here).
