This is an example practice guide excerpted from one of
the 800-page Practice Guide books published by
Acute Care Horizons, LLC. For info on this book go to:
http://www.acutecarehorizons.com
VENOUS THROMBOEMBOLIC
DISEASE PRACTICE GUIDE
When using any Practice Guide, always follow the Guidelines of Proper Use
(page 16).
Definition
● Formation of thrombus within veins that may or may
not propagate toward the central circulation
Differential diagnosis
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Cellulitis
Hematoma
Superficial thrombophlebitis
Varicose veins
Contusion or muscle strain/tear
Arterial insufficiency
Postphlebitic syndrome
Dependent edema
Lymphedema
Baker’s cyst
Considerations
● Deep vein thrombosis (DVT) and pulmonary embolism
(PE) are manifestations of the same disease process
● DVT involves the legs most commonly, followed by the
arms
● Early recognition and treatment are very important in
decreasing morbidity and mortality
● Thrombus damages vein valves causing reflux of blood
and postphlebitic syndrome — chronic edema and
venous stasis ulcers
● Most DVT’s develop complete or partial recanalization
and collaterals over time
● Proximal large vein thrombosis can cause pulmonary
embolism
● PE occurs in ~ 10% of DVT
● Calf DVT may produce 1/3 of PE
● Most DVT is occult and resolves spontaneously
● Up to 40% of DVT patients when diagnosed have
silent PE
● Paradoxic emboli may pass through an atrial septal
defect and cause a CVA or distal arterial occlusion
● D-dimers remain elevated for 7 days after thrombus
formation
Risk factors
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Cancer
Advanced age
Immobilization > 3 days
Major surgery in the prior 4 weeks
Clotting disorders are common risk factors for
venous thromboembolism (VTE)
• 5–10% of VTE is from protein C, protein S or
antithrombin lll disorders
• Factor V Leiden mutation
Most common risk factor is prior VTE
CHF
AMI
CVA
Sepsis
Estrogens
IV drug abuse
Pregnancy and postpartum period
Thrombocytosis and polycythemia vera
Virchow triad for formation of thrombus
● Venous stasis
● Activation of coagulation system
● Vein damage
Goals of DVT treatment
● Reduce morbidity
● Prevent postphlebitic syndrome
● Prevent pulmonary embolism
Signs and symptoms
DVT
● Extremity pain
● Involved area red and swollen
● May be asymptomatic
Severe DVT
Phlegmasia alba dolens
x Blanched leg appearance
x Massive iliofemoral thrombotic occlusion
Phlegmasia cerulea dolens
Follows phlegmasia alba dolens
Associated with arterial spasm
Risk of gangrene
Shock may occur
Mortality 20–40% if venous gangrene
develops
x Notify or consult promptly a physician for
phlegmasia of any type
x May be treated conservatively with
heparin and elevation if no ischemia
present
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Pulmonary embolism
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Hypoxemia
Chest pain
Shock or hypotension
May have no symptoms or findings
EKG
• Sinus tachycardia most common
• Nonspecific STT wave changes or with
ischemic appearing biphasic T waves in V2
and V3
• New right bundle branch block
• S1Q3T3 pattern in 19%
• Right axis deviation in 5%
• Left axis deviation in 10%
• New onset atrial fibrillation
• EKG may be normal in 13%
Evaluation options
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Chest x-ray
CBC if fever or tachycardia present
BMP if diabetic or tachycardia present
D-dimer (if negative with Well’s criteria 0–1 makes PE
unlikely)
● CT chest (see below)
● Apply Well’s pulmonary embolism and DVT criteria and
chart Well’s score as indicated
● Extremity venous ultrasound for moderate to high
probability Well’s criteria as indicated
● CT abdominal/pelvis scan for suspected intraabdominal or pelvic DVT
● Record positive or negative calf tenderness and
Homan’s sign
Evaluation with D-dimer
D-dimer (LIA method) — some methods currently in use
not reliable
● Useful if negative at cutoff value to rule out DVT
or PE
● Negative D-dimer with low to moderate
probability Well’s DVT or PE score largely excludes
venous thromboembolic disease
● Well’s DVT criteria high probability: order
ultrasound scan regardless of D-dimer result
● If positive — not as useful as a negative result
which usually rules out VTE (venous
thromboembolic) disease
● Frequently positive with
• Hospitalization in past month
• Chronic bedridden or low activity state
• Increasingly positive with age without
significant acute disease process
• CHF
• Chronic disease processes
• Edematous states
Well’s DVT criteria
● One point each:
• Active cancer
• Paralysis/recent cast immobilization
• Recently bedridden > 3 days or surgery < 4
weeks
• Deep vein tenderness
• Entire leg edema
• Calf swelling > 3 cm over other leg
• Pitting edema > other calf
• Collateral superficial veins
● Two points — alternative diagnosis less likely
High probability: ≥ 3 points
Moderate probability: 1–2 points
Low probability: 0 points
Well’s PE criteria score 3 or greater consider Ddimer and CT chest PE protocol
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Suspected DVT = 3
Alternative diagnosis less likely than PE = 3
Heart rate > 100 = 1.5
Immobilization/surgery past 4 wks. = 1.5
Previous DVT/PE = 1.5
Hemoptysis = 1
Cancer past 6 months = 1
Well’s score ≥ 6: order CTA chest PE protocol
Document positive or negative Homan’s sign or
calf tenderness regardless of Well’s scores
Document PERC and/or Well’s scores when
appropriate
Pulmonary Embolism Rule-out Criteria (PERC Rule)
(Reportedly decreases significantly the likelihood of
pulmonary embolism if all 8 criteria met)
● Age < 50
● Pulse oximetry > 94%
● Heart rate < 100
● No history of DVT or VTE
● No hemoptysis
● No estrogen use
● No unilateral leg swelling
● No recent surgery or trauma hospitalization past 4
weeks
Treatment options
DVT
May be treated as outpatient if none of the following
present
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Pulmonary embolism
Significant cardiopulmonary comorbidities
Pregnancy
Morbid obesity
• Homeless
• Creatinine > 2 mg/dL
• No follow up
• Inherited bleeding disorder
• Iliofemoral DVT
• Contraindications to anticoagulation
• Disorder of coagulation
• Patient does not want to be discharged
● Enoxaparin (Lovenox) 1 mg/kg SQ q12hr (1
mg/kg SQ q24hr if creatinine clearance<30
ml/minute)
OR
● Heparin (unfractionated) 80–100 U/kg IV loading
dose and 15–18 U/kg/hour IV (keep PTT 2–2.5
times normal
OR
● Fondaparinux (Arixta) – no INR or PTT monitoring
needed
• < 50 kg: 5 mg SQ qday
• 50–100 kg: 7.5 mg SQ qday
• > 100 kg: 10 mg SQ qday
Stop all heparins if platelet count drops to 100,000,
or a 50% decrease in baseline platelet count occurs,
or 30% decrease in platelet count with new
thrombus formation development (heparin
induced thrombocytopenia) — a life threatening
immune process
● Warfarin (Coumadin)
• 2–10 mg PO qday to achieve INR 2–3
• Treatment for 3–6 months
• Can cause initially a transient
hypercoagulable state if started without
heparin treatment
• Has a myriad of drug and other substances
interactions
• Can cause life threatening hemorrhage
• Read drug information before using to
determine interactions and patient risks
● Thrombin inhibitors
• Argatroban for heparin-induced
thrombocytopenia
● Thrombolytics
• Use under direction of physician
• For severe iliofemoral DVT (Phlegmasia
cerulea dolens) catheter directed
● Mechanical extraction
• Consult vascular surgeon or interventional
physician with appropriate skill set
Pulmonary embolism
● Same medication treatment as DVT
● Oxygen
● IV NS 500–1,000 bolus if hypotensive and notify
physician promptly
• Thrombolytics may be considered if PE caused
hypotension is present
DVT prophylaxis
● Enoxaparin (Lovenox) 40 mg SQ q24h
OR
● Heparin (unfractionated) 5,000 units SQ q8–12h
For admitted patients with any of the following
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Age > 60 years
CHF
Systemic infection
History of DVT or PE
Inflammatory disorders
Cancer
ICU admission
Hypercoagulable state
Immobilization ≥ 3 days or severely
compromised ambulation
Discharge criteria
● DVT not meeting exclusionary criteria above
● Discuss with physician
Consult criteria
● All DVT and PE patients, or suspected DVT/PE
diagnosis
● Tachycardia
● Hypotension or relative hypotension (SBP < 105
with history of hypertension)
● Dyspnea