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2451105796280Investigations00Investigations15525755796916D-dimer: do if Well’s score ≤1 Level decreased by heparin; normal levels ? with age 70-90% sensitivity in DVT’s present <1/52; ELISA 96-98% sensitivity, 55-70% specificity; latex lower but cheaper and quicker; simpliRED 2nd generation latex 85% sensitivity, 70% specificity; VIDAS 95% sensitivity, 40% specificity) False negatives in old DVTs and overwhelming thrombosis; false positives in infection, cancer, tissue injury, CCF, ACS, CVA, pregnancy, ARF, sickle cell disease, aortic dissection If low risk and negative: excludes DVT If mod risk and negative: 1.5-7% risk of DVT If high risk and negative: 8-37% risk of DVT USS: do if Well’s ≥2 Loss of vein compressibility; >95% sensitivity and specificity for above knee; 70% sensitivity for below knee; not good for iliacs 2-point USS – much quicker; >95% sensitivity and specificity done in ED by experienced sonographer; visualises 99% vesselsVenography: high sensitivity; painful; requires contrast; causes DVT in 1%MRI: 80% sensitivity for below knee; MRI venography 100% sensitivity and specificity00D-dimer: do if Well’s score ≤1 Level decreased by heparin; normal levels ? with age 70-90% sensitivity in DVT’s present <1/52; ELISA 96-98% sensitivity, 55-70% specificity; latex lower but cheaper and quicker; simpliRED 2nd generation latex 85% sensitivity, 70% specificity; VIDAS 95% sensitivity, 40% specificity) False negatives in old DVTs and overwhelming thrombosis; false positives in infection, cancer, tissue injury, CCF, ACS, CVA, pregnancy, ARF, sickle cell disease, aortic dissection If low risk and negative: excludes DVT If mod risk and negative: 1.5-7% risk of DVT If high risk and negative: 8-37% risk of DVT USS: do if Well’s ≥2 Loss of vein compressibility; >95% sensitivity and specificity for above knee; 70% sensitivity for below knee; not good for iliacs 2-point USS – much quicker; >95% sensitivity and specificity done in ED by experienced sonographer; visualises 99% vesselsVenography: high sensitivity; painful; requires contrast; causes DVT in 1%MRI: 80% sensitivity for below knee; MRI venography 100% sensitivity and specificity2457453271520Assessment00Assessment1551305327088570% of hospitalised patients are asymptomatic; 1/3 patients asymptomatic overall; examination 75% sensitivity, 45% specificity; ? diameter >2cm (60% sensitivity, 70% specificity), superficial thrombosis, tenderness, Homan’s sign, feverWell’s Score: -2 for: alternative diagnosis more likely +1 for: cancer in last 6/12 / immobilization / bed bound >3/7 or major surgery <12/52 tender along veins / entire leg swelling / >3cm ? diameter / pitting oedema collaterals Low probability: 0 5% incidence of DVT Moderate probability: 1-2 14% incidence of DVT High probability: ≥3 50-80% incidence of DVTModified Well’s Score: as above but +1 for PMH DVT DVT unlikely: ≤1 3-9% incidence of DVT DVT likely: ≥2 20-35% incidence of DVT0070% of hospitalised patients are asymptomatic; 1/3 patients asymptomatic overall; examination 75% sensitivity, 45% specificity; ? diameter >2cm (60% sensitivity, 70% specificity), superficial thrombosis, tenderness, Homan’s sign, feverWell’s Score: -2 for: alternative diagnosis more likely +1 for: cancer in last 6/12 / immobilization / bed bound >3/7 or major surgery <12/52 tender along veins / entire leg swelling / >3cm ? diameter / pitting oedema collaterals Low probability: 0 5% incidence of DVT Moderate probability: 1-2 14% incidence of DVT High probability: ≥3 50-80% incidence of DVTModified Well’s Score: as above but +1 for PMH DVT DVT unlikely: ≤1 3-9% incidence of DVT DVT likely: ≥2 20-35% incidence of DVT15513052788285Bleeding, thrombosis, purpura fulminans, multi-organ failure, focal ischaemia, gangrene, oliguria, renal cortical necrosis, ALI00Bleeding, thrombosis, purpura fulminans, multi-organ failure, focal ischaemia, gangrene, oliguria, renal cortical necrosis, ALI15513051494155External vessel compression: pregnancy, massesIn vessel wall: trauma, surgery, vasculitisIn blood: stasis (NWB, rigid immobilisation, bed rest >48 hours, travel, external fixation, paralysis, CCF, major trauma, major surgert, obesity); hormynal (pregnancy, post-partum, OCP, HRT); hyperviscosity; smoking, nephrotic syndrome; diabetes; cancer (esp adenocarcinoma or metastatic); haematological problems (eg. Thrombophilia, plasminogen deficiency, platelet problems); hyperhomocystinaemia; heparins; eldery00External vessel compression: pregnancy, massesIn vessel wall: trauma, surgery, vasculitisIn blood: stasis (NWB, rigid immobilisation, bed rest >48 hours, travel, external fixation, paralysis, CCF, major trauma, major surgert, obesity); hormynal (pregnancy, post-partum, OCP, HRT); hyperviscosity; smoking, nephrotic syndrome; diabetes; cancer (esp adenocarcinoma or metastatic); haematological problems (eg. Thrombophilia, plasminogen deficiency, platelet problems); hyperhomocystinaemia; heparins; eldery15513059639301:1000 overall; 1:100,000 in childhood; 1:100 in elderly; bilateral in 30%; in 6% patients with lower limb injury; in 15% if immobilised >4/52; 8% annual recurrence rate if unprovoked, 2% if risk factors001:1000 overall; 1:100,000 in childhood; 1:100 in elderly; bilateral in 30%; in 6% patients with lower limb injury; in 15% if immobilised >4/52; 8% annual recurrence rate if unprovoked, 2% if risk factors245745964565Epidemiology00Epidemiology2463801494155Risk Factors00Risk Factors2495552788285Complications00Complications246380330200DVT00DVT328295482600Management00Management1653540482600Elevation; ambulation; analgesia; stockings (wear for 2yrs; ? risk of VTE by 50%; ? post-thrombotic syndrome by 50%)Anticoagulation: ? risk of PE to 5%; ? recurrent thrombosis in 1st 3/12 by 80-90%; doesn’t ? risk of post-phlebitic syndrome Mod/high probability: discharge after dose of heparin (40mg enoxaparin OD or 5000iu heparin BD) USS within 12 hours If DVT: continue LMWH until INR therapeutic (minimum 5/7, must overlap warfarin by minimum 4/7) continue for 3/12 (life long if thrombophilia; not needed for below knee DVT unless continued risk factors (eg. Thrombophilia, ongoing POP); propagation occurs in 20% below knee DVT’s therefore do repeat USS at 3-7/7; if not given heparin, give aspirin Treat as inpatient if: severe oedema of whole lower limb; thrombus above groinThrombolysis: can ? incidence of post-phlebitic syndrome, lower incidence of venous ulceration, complete lysis of thrombus in 30-40%; risk of embolism; indicated if massive iliofemoral thrombosis or young patient with extensive venous thrombosis <1/52; SKA 250,000iu IV over 30mins 100,000iu/hr for 24 hoursIVC filter: if high risk from anticoagulation (eg. Mutliple trauma); ? rate of PE from 5% to 1% in 1st weekThrombectomy: if vital function of lower limb threatenedIn superficial thrombophlebitis of proximal 1/3 long saphenous vein, extension into deep system must be excluded by USS, and full anticoagulation is recommended even if there is no DVT (propagation into deep system will occur in 15%)If distal superficial thrombophlebitis, do follow up USS in 72 hours and anticoagulate if progresses into deep system; Otherwise treat superficial thrombophlebitis with RICE, analgesia, NSAIDs; resolves in 3- 4/5200Elevation; ambulation; analgesia; stockings (wear for 2yrs; ? risk of VTE by 50%; ? post-thrombotic syndrome by 50%)Anticoagulation: ? risk of PE to 5%; ? recurrent thrombosis in 1st 3/12 by 80-90%; doesn’t ? risk of post-phlebitic syndrome Mod/high probability: discharge after dose of heparin (40mg enoxaparin OD or 5000iu heparin BD) USS within 12 hours If DVT: continue LMWH until INR therapeutic (minimum 5/7, must overlap warfarin by minimum 4/7) continue for 3/12 (life long if thrombophilia; not needed for below knee DVT unless continued risk factors (eg. Thrombophilia, ongoing POP); propagation occurs in 20% below knee DVT’s therefore do repeat USS at 3-7/7; if not given heparin, give aspirin Treat as inpatient if: severe oedema of whole lower limb; thrombus above groinThrombolysis: can ? incidence of post-phlebitic syndrome, lower incidence of venous ulceration, complete lysis of thrombus in 30-40%; risk of embolism; indicated if massive iliofemoral thrombosis or young patient with extensive venous thrombosis <1/52; SKA 250,000iu IV over 30mins 100,000iu/hr for 24 hoursIVC filter: if high risk from anticoagulation (eg. Mutliple trauma); ? rate of PE from 5% to 1% in 1st weekThrombectomy: if vital function of lower limb threatenedIn superficial thrombophlebitis of proximal 1/3 long saphenous vein, extension into deep system must be excluded by USS, and full anticoagulation is recommended even if there is no DVT (propagation into deep system will occur in 15%)If distal superficial thrombophlebitis, do follow up USS in 72 hours and anticoagulate if progresses into deep system; Otherwise treat superficial thrombophlebitis with RICE, analgesia, NSAIDs; resolves in 3- 4/52 ................
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