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
| Feature | Score |
|---|---|
| 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 generally managed through ED and GP’s
- Does the patient need an Ultrasound ? (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)
- Consultants/MG’s can consider using age adjusted D-Dimer in the over 50’s (10ng/ml per year of age)
- High Risk Wells’ (≥2) OR Low Risk and High D-Dimer – Go to Step 2
- 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)
- Exclusions to Outpatient/Ambulatory Pathway:
- 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
- Outpatient Pathway:
- Initial Dalteparin – if not contraindicated; [Trust Guide] OR [BNF]
- Order Lower leg Ultrasound: remember Wells’ and D-Dimer are required
- Rivaroxaban: 15mg BD 21 day
- Patient advice leaflet [PDF pg:2]: U/S will either discontinue meds or arrange DVT clinic FU
- Further follow-up will be through GP
- Inpatient Pathway:
- Commence Dalteparin – if not contraindicated; [Trust Guide] OR [BNF]
- Ref to AAU/MAU
PDF:dvt
