Deep Vein Thrombosis (DVT)

It is worth remembering that HRI and CRH have different processes for the management of DVT see Management section.

Signs and Symps

No single feature is diagnostic:

  • Single limb oedema – Most specific
  • Leg pain – 50% but is nonspecific
  • Calf pain on dorsiflexion of the foot (Homan’s sign)
  • Tenderness of deep veins – 75% of patients
  • Warmth AND/OR erythema (although blanching is possible)
  • A palpable, indurated, cordlike, tender subcutaneous venous segment

Wells’ score

Even if the wells score is high risk we still need a D-Dimer as it will guide what happens in the event of a negative initial scan

FeatureScore
Entire Leg swollen+1
Tender over deep veins+1
Pitting oedema (greater in symptomatic leg)+1
Immobilisation of limb+1
Previous DVT/PE+1
Active Cancer+1
Bed Ridden (>3 days within last 4 weeks)+1
Collateral superficial veins
(non-varicose)
+1
Calf swelling >3cm (in symptomatic leg)+1
Alternative diagnosis (equally or more likely than DVT)-2

Investigations

  • FBC
  • Renal function
  • Liver function
  • CRP
  • Clotting
  • D-Dimer

Management

CRH – Admit to AAU/MAU

HRI – Our protocol is initiated by ED and GP’s

  1. Wells’ Actions
    • Low Risk Wells’ (<2) & Low D-Dimer (consider using age adjusted) – No further investigation required (Remember: it is known there are DVT’s in this group but they don’t progress to become an issue, if they represent reconsider diagnosis)
    • High Risk Wells’ (≥2) OR Low Risk and High D-Dimer – Go to Step 2
  2. Is the patient Ambulatory?
    • Unable to Go home and return for U/S
    • <18yrs
    • Pregnant/Post-partum/Lactating
    • Suspected PE
    • Hypertension (SBP >180 OR DBP >115)
    • CKD 5 (eGFR <15)
    • Liver Failure
    • Bleed Risk (e.g. Oesophageal varices, major surgery, major trauma, intracranial bleed <4/52 etc.)
    • Allergy to Rivaroxaban
  3. Ambulatory:
    • Order Lower leg Ultrasound: remember Wells’ and D-Dimer are required
    • Rivaroxaban: 15mg BD, in 3 post dated weekly scripts
    • Patient advice leaflet [PDF pg:2]U/S will either discontinue meds or arrange DVT clinic FU
  4. Non-Ambulatory:

PDF:dvt

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