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Deep Vein Thrombosis (DVT) / Thrombophlebitis: Assessment & Urgent Referral

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Deep Vein Thrombosis (DVT) / Thrombophlebitis: Assessment & Urgent Referral WSCC Clinics Protocol Adopted: 09/05 To be revised: 02/09 Deep Vein Thrombosis (DVT) / Thrombophlebitis: Assessment & Urgent Referral This condition requires urgent referral. Untreated proximal DVT can lead to pulmonary emboli in up to 50% of patients. 95% of all pulmonary emboli are from DVT and have a 30% mortality rate. There is currently no consensus as to whether the empirical judgment of the practitioner or utilization of one of the published decision- making tools is more accurate in deciding which patients should be referred for diagnostic testing. Information on both approaches is contained in this document. Background pulmonary embolism (PE), and post- thrombotic syndrome. Approximately 2 million people a year develop deep vein thrombosis (DVT). In about half of Proximal deep vein thrombosis involves the these patients, the DVT is asymptomatic until popliteal vein or more proximal veins. 80% of a pulmonary embolism occurs. (Caprini 2005) symptomatic patients with confirmed DVT In rare cases, the embolism will travel through have proximal thrombosis. Proximal DVT a patent foramen ovale in the heart wall and leads to a much higher incidence of result in a stroke. pulmonary embolism than does distal. The formation of venous thrombosis usually Distal deep vein thrombosis involves the begins when platelets aggregate at the site of posterior tibial vein in the calf and leads to a endothelial damage. Stasis encourages much lower incidence of pulmonary thrombus formation, followed by the embolism. deposition of fibrin, leukocytes and erythrocytes. The process begins in the cusps Note: Although distal DVT by itself rarely of venous valves. The resulting thrombus may causes pulmonary emboli, in about 30% of move along the vessel as a free-floating clot cases, the distal thrombosis expands upward and the organized thrombus then adheres in to the proximal veins and causes proximal a venous sinus in about 7-10 days. The DVT. When this occurs, it usually occurs vessel may become occluded. The thrombus within a week of initial presentation (Kearon may eventually extend all the way up the leg 2005). and into the pelvis. Assessment In the case of venous thrombophlebitis, secondary inflammatory changes occur once Clinical suspicion is based on a combination the thrombus adheres to the vessel wall. of clinical signs and symptoms, as well as on Thrombo-phlebitis ultimately destroys the the assessment of risk factors. The classic venous valves in the area. “Central presentation is a patient with a leg that is recanalization” may eventually restore blood painful, warm, red, swollen and tender. But flow through the area. DVT may not present in this way, and this classic presentation is not always caused by Complications of thrombophlebitis/DVT DVT. The clinical signs and symptoms tend to include chronic vein insufficiency (partially be neither sensitive nor specific (Goodacre obstructed veins with faulty valves), 2005, Tapson 2005). Deep Vein Thrombosis: Assessment and Urgent Referral Page 1 of 12 The practitioner may simply consider the Major Risks* combination of clinical risks, signs and symptoms, and arrive at an empirical decision Clinical suspicion of DVT is based partly on to refer for further testing, or using a decision- assessing risks. Major risks include the making tool. Wells has a 9-point standardized following: scoring system, commonly used to assign the patient to a low, moderate or high risk group • Active cancer. This includes treatment (see Appendix 1). within the last 6 months or currently receiving palliative treatment. The accuracy of Well’s scoring system is • Paralysis, paresis, or recent controversial. A 2005 meta-analysis of 54 immobilization casting of the lower studies suggested that this point system extremity (< 1 month). 59% of DVT appeared to be useful in clinics or emergency cases are attributable to a current departments. A low score had a 0.25 negative hospitalization or a recent nursing home likelihood ratio and a high score carried a 5.2 stay. (Heit 2002) positive likelihood ratio (Goodacre 2005). • Recently bedridden. 3 days or more. However, in a cross-sectional study of 1295 • Major surgery within the previous 12 primary care patients in the Netherlands weeks requiring general or regional (Oudega 2005), the low risk categorization anesthesia. Leg or pelvic surgery or missed 12% of patients with DVT as opposed prostatectomy is of special concern. to the 3-5% reported in Goodacre’s meta- analysis. Further, Oudega calculated a 0.45 • Previous DVT. Increases risk 2-3X. About one third of patients with an initial negative likelihood ratio—considerably higher episode of deep vein thrombosis will than the 0.18 reported in Wells’ original study present during the following year with or the 0.25 reported by Goodacre. signs and symptoms that suggest a Oudega’s meta-analysis contained four recurrence (whereas only one in three of these patients actually have a studies revealing that physician judgment of a recurrence). (Lensing 1993) low risk patient had a negative likelihood ratio of 0.25—the same accuracy reported when • Age over 75 years. using the Wells instrument. Based on current • History of pulmonary embolism. information, either empirical judgment or • Family history of thrombosis. One of Wells tool appear to be viable options. the most frequently missed risk factors. Further, even if a standardized scoring (Caprini 2005) system is used, the practitioner must still use • Patients with laboratory or genetic risk his/her empirical judgment. factors for coagulation: positive Factor V Leiden, Prothrombin 20210A, or lupus Wells also has a revised 10-point tool that anticoagulant; elevated serum divides patients more simply into high and low homocysteine or anticardiolipin risk. This tool may be more effective, although antibodies. it has not been as extensively studied (see • Heparin-induced thrombocytopenia Appendix 2). Also contained in this document (HIT). is a third decision-making tool (see Appendix 3) used in a hospital setting to determine the Additional Risks need for prophylactic anti-coagulation therapy, which could also be used to help • Family history of thromboembolism or guide referral decisions in a chiropractic blood clotting disorders. Presents a risk setting (Caprini 2005). if at least one first-degree relative was diagnosed with DVT. • After CVA. 1/2 will develop DVT. * The author of this document designated risks as “major” based on the weightings given in the decision-making tools in the appendices. Deep Vein Thrombosis: Assessment and Urgent Referral Page 2 of 12 • After MI. 1/3 will develop DVT. Palpation • Obesity. • Local tenderness along course of deep • Varicose veins. venous system (present in about 50% of • Oral contraceptive/HRT. Risk increases cases). (Lohr 2005) 2X. Concomitant progestin use increases • Erythema of the area. the risk over estrogen alone. (Smith 2004) • A palpable “hard cord” over the • Older age. Risk increases over the age of popliteal, femoral or iliac veins. 40 years; exponential increase over 50. (Waterhouse 2001) • Pregnancy. Risk increases up to 4 weeks • Temperature change. Increased local post-partum (Miron 2000). heat in the case of thrombophlebitis or • Past history of difficult pregnancy. decreased in deep vein thrombosis. History of stillborn, miscarriage, premature Caution: The practitioner should avoid birth with toxemia may be signs of sustained, forceful palpatory pressure if thrombophilia in the mother (Caprini there is a high index of suspicion for DVT. 2005). This caution is due to the risk of triggering • Long air flights. The risk is highest within a pulmonary embolism. the first 2 weeks. In one Australian study, the annual risk of thromboemboilism was Homan’s sign. This classic test should no increased by 12% in those experiencing longer be performed because it is not one long flight per year. The degree of risk considered to be diagnostic. It is present in versus the exact length of flight was not only about 8% of cases, is non-specific, and calculated (Kelman 2003). However, there is also concern about triggering an flights longer than 6 hours have been embolism. (Lohr 2005, Waterhouse 2002) identified as a risk (Miron 2000). Another study found that flights of 8 hours or Additional physical exam procedures longer doubled the risk for isolated calf The practitioner should also check oral thrombosis and also increased the risk for temperature and pulses in lower leg. DVT (Schwarz 2003). Long flights serve *Physical Positive Negative Sensitivity Specificity as a risk factor alone, but may also Findings LR LR increase pre-existing risk factors, Inspection: increasing the risk of patients with Any Calf or thrombophilia 16X and oral contraceptive Ankle 41-90% 8-74% --- -- Swelling use 14X. (Eklorf 2005, Martinelli 2003) Asymmetric 61% 71% 2.1 0.6 • Tissue trauma. Calf Swelling Thigh 50% 80% 2.5 0.6 • Systemic lupus erythematosis. Swelling • Lower limb arteriography. Superficial Venous 29-33% 82-85% cal cal Dilation Erythema 16-48% 61-87% --- --- Physical Exam Findings Superficial Thrombo- 5% 95% cal cal Observation phlebitis • Entire leg swollen. Thigh swelling has a Palpation: Tenderness 17-85% 10-65% --- --- reported 2.5 positive LR. Asymmetric • Calf swelling at least 3 cm larger than Skin 42% 63% cal cal that of the asymptomatic leg (measured Coolness Asymmetric 29-71% 51-77% --- --- 10 cm below tibial tuberosity.) Skin Warmth A Palpable • Pitting edema (greater in symptomatic 15-30% 73-85% --- --- leg). Ankle swelling in general is present “Cord” in about 80% of DVT patients. (Lohr 2005) * If the reported sensitivity or specificity varied more than 10 percent, • Dilated collateral superficial veins then likelihood ratios were not calculated. For “Positive LR” - the larger the number, the stronger the predictive power of a positive test. For (nonvaricose). “Negative LR” - the smaller the number, the stronger the predictive power of a negative test. Adapted from Anand 1998, McGee 1998, and Orient 2000. Deep Vein Thrombosis: Assessment and Urgent Referral Page 3 of 12 Urgent Referral • The supervising clinician should follow up on all time-sensitive referrals within 24 It is important to refer suspected DVT hours.
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