Deep Vein Thrombosis (DVT)

Deep Vein Thrombosis (DVT)

Medicine > General medicine > Deep Vein Thrombosis (DVT)

Care map information

Information resources Updates to this care for patients and carers map

Hauora Maori

Presentation

History & clinical examination

Immediate referral to WAM or ED

RED FLAGS

Calculate Wells Clinical Score

Pasifika

Wells Score Assessment 2

Wells Score Assessment =1 or 0

Wells Score Assessment General medicine > Deep Vein Thrombosis (DVT)

1 Care map information

Quick info: Scope: ? diagnosis and treatment of Deep Vein Thrombosis (DVT) ? adults 18 years and over Out of scope: ? primary prevention of DVT ? children 17 years of age Definition of DVT: A condition marked by the formation of a thrombus within a deep vein (as of the leg or pelvis) that may be asymptomatic or be accompanied by symptoms (as swelling and pain) and that is potentially life threatening if dislodgment of the thrombus results in pulmonary embolism--abbreviation DVT References: See Provenance Certificate for full list of references.

2 Information resources for patients and carers

Quick info: Patient will receive verbal and written information regarding DVT, investigations for and management of DVT as part of the WAM discharge process as appropriate to their diagnosis. Information sheets are intended to provide supportive information to patients / carers / family following consultation with the doctor. Patients discharged on Clexane and Warfarin will receive a resource pack containing the Red Warfarin book, Warfarin Handout and A5 instruction sheets for Clexane and DVT (as per Warfarin Guideline). Patient Resources: ? What is DVT and treatment ? Preventing DVT when travelling ? Clexane ? Family guide to clexane administration ? warfarin vs. dabigatran ? warfarin information brochure ? Compression Hosiery

3 Updates to this care map

Quick info: Date of draft publication: April 2016 For further information on contributors and references please see the care map's Provenance.

4 Hauora Maori

Quick info: As a practitioner you will work with Maori whanau/families. Each Maori whanau is diverse with their own set of values and beliefs, inherited, practised and passed down from generation to generation. There are some important things that you should be mindful of when working with Maori individuals and their whanau from a holistic approach to working in a Whanau ora or family / whanau centred way. Key enablers that you should be aware of when working with Maori whanau/families are: ? building relationships and gaining trust ? effective communication with whanau /families ? understanding and involving whanau/ families in the treatment planning and care management

Published: 14-Sep-2016 Valid until: 28-Feb-2018 Printed on: 04-Dec-2017 ? Map of Medicine Ltd

This care map was published by Whanganui District. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.

Page 2 of 10

Deep Vein Thrombosis (DVT)

Medicine > General medicine > Deep Vein Thrombosis (DVT)

? practical things to be mindful of when working with Maori whanau so that you do not breech Tikanga/Principles and practices that are important in Te Ao Maori/the Maori world

Common terms and definitions are noted here.

5 Pasifika

Quick info: Our pasifika community: ? is a diverse and dynamic population

? more than 22 nations represented in New Zealand ? each with their own unique culture, language, history, and health status ? share many similarities which we have shared with you here in order to help you work with pasifika patients more effectively The main Pacific nations in New Zealand are ? Samoa, Cook Islands, Fiji, Tonga, Niue, Tokelau and Tuvalu Acknowledging The FonoFale Model (pasifika mode of health) when working with pasifika peoples and families. Acknowledging general pacific guidelines when working with pasifika peoples and families: ? cultural protocols and greetings ? building relationships with your pacific patients ? involving family support, involving religion, during assessments and in the hospital ? home visits ? pasifika phrasebook

6 Presentation

Quick info: Deep vein thrombosis (DVT) is most likely if calf is swollen >3cm compared to asymptomatic measured 10cm below tibial tuberosity. Signs of suspected DVT are symptoms of inflammation (pain and tenderness) and obstruction (swelling and pitting oedema). Patients with symptoms suggestive of DVT will have a health and physical assessment by their GP, after-hour/casual GP service WAM or ED. This includes patients presenting to WAM and/or ED with suspected DVT after hours, weekends, and/or public holidays.

7 History & clinical examination

Quick info: Health History: ? consider risk factors and red flags Physical Assessment: Perform a thorough examination of the legs (including measurement of calf girth, oedema etc.). Record onset, location and character of patient's leg pain and swelling. Deep vein thrombosis (DVT) is most likely if calf is swollen >3cm compared to asymptomatic measured 10cm below tibial tuberosity. NB: The Homans sign has no clinical value in assessing suspected DVT. Risk factors include: ? increasing age ? obesity ? varicose veins ? family history ? Thrombophilia ? other thrombotic states e.g:

Published: 14-Sep-2016 Valid until: 28-Feb-2018 Printed on: 04-Dec-2017 ? Map of Medicine Ltd

This care map was published by Whanganui District. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.

Page 3 of 10

Deep Vein Thrombosis (DVT)

Medicine > General medicine > Deep Vein Thrombosis (DVT)

? cancer ? heart failure ? recent MI ? chronic renal failure ? stroke etc. ? combined oral contraceptive ? oral oestrogen HRT ? Raloxifene/ Tamoxifen ? pregnancy/ puerperium ? immobility/ travel immobility ? hospitalisation e.g. recent surgery ? anaesthesia ? central venous catheters [7]

8 Immediate referral to WAM or ED

Quick info: WAM Phone number: 06 3481 300 Fax number: 06 3481 299 Refer immediately to ED if: ? significant clinical concerns e.g: shortness of breath or chest pain, patient feeling light headed or rapid pulse ? suspected pulmonary embolus (PE), or the patient is acutely unwell and/or has active multiple co-morbidities NB: should the primary care practice have an anticoagulant preference they should advise on the referral e.g: If patient is known to be non-compliant with blood tests or: ? if clinically mitigating circumstances exist e.g:

? severe dementia, limited life expectancy, high falls risk ? inability to cope with anticoagulation monitoring ? due to sporting activities Consideration of Warfarin vs. Dabigatran should be made by the GP with Warfarin being the first choice for most patients. GP to complete HAS-BLED bleeding risk score tool to assist with anticoagulant decision making. HAS-BLED score to be included in the ED referral.

9 RED FLAGS

Quick info: Refer immediately to WAM if: ? suspected deep vein thrombosis (DVT) in pregnancy ? suspected Pulmonary Embolism (PE) ? recent cessation of thrombolytic medication Refer immediately to ED if: ? significant clinical concerns e.g. shortness of breath or chest pain, patient feeling light headed or rapid pulse Contraindications to anti-coagulation therapy include: ? haemophilia or any other known bleeding disorders ? active bleeding ? platelets General medicine > Deep Vein Thrombosis (DVT)

10 Calculate Wells Clinical Score

Quick info: The Wells Rule Score is used to identify the clinical probability for DVT. The score is based on a summation of risk factors, symptoms and signs of DVT, following history and examination. An important contribution to the score is the presence or absence of an alternative diagnosis when it is as likely as or greater than DVT. Fill in Wells Score Sheet to calculate score: ? calculate Wells Score

? score Sheet

11 Wells Score Assessment 2

Quick info: Where the wells score is 2: ? deep vein thrombosis (DVT) cannot be ruled out as a likely diagnosis ? phone referral to WAM and arrange an ultrasound ? fax through outbox referral form including Wells score NB: Where there are several referrals for investigation of DVT, patients will be seen in order of presentation. High clinical probability of DVT: ? D-dimer testing is not indicated ? Compression Ultrasound (CUS) must be performed in these cases due to high prevalence of DVT (19-46%) ? positive CUS or confirmation of DVT indicates the need for clinical management

12 Wells Score Assessment =1 or 0

Quick info: Where the Wells Score =1 or 0: ? deep vein thrombosis (DVT) cannot be ruled out as a likely diagnosis ? organise URGENT D-dimer ? write Wells score on lab request form ? organise other blood tests; if no recent full blood count, liver function or renal function tests ? GP to write contact number, including after hours contact number on blood request form ? lab to contact GP with results ? the GP remains responsible for taking action depending on the result of D-dimer ? provide patient with education on the fact that a Wells score of 1 or 0 does not necessarily mean they have a DVT, nor does a

positive D-dimer, explain to patient what a D-dimer is Low clinical probability of DVT:

? approximately 40% of patients will have a low score ? D-dimer is the next appropriate investigation ? more than two thirds of these patients will have a negative D-dimer ( General medicine > Deep Vein Thrombosis (DVT)

Consider contra-indications to anti-coagulation therapy when deciding on the next appropriate step for patient: ? haemophilia or any other known bleeding disorders ? active bleeding ? thrombocytopenia Associated other comorbidities: ? clotting disorder

13 Wells Score Assessment Deep Vein Thrombosis (DVT)

No further investigation for DVT indicated. Where the D-dimer is negative, discuss the most likely diagnosis with the patient and arrange follow up as appropriate. Discuss potential red flags and self management. A negative D-dimer is considered to be ................
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