DVT pathway 2021

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

Management [08-18:00]

  • Senior Triage in A&E : Middle grade/Consultant physician OR Band 7 sister or above
    • Suspicion of DVT (Deep Vein Thrombosis)
    • Alternative Red-Flag diagnosis ruled out: Cellulitis, Ischaemic limb, MSK, Phlegmasia Cerulea/Alba Dolens
    • No AAU/SDEC exclusions: NEWS2 >4, New Oxygen Requirement, New/Acute Confusion

All of above  – refer straight to AAU/SDEC

Management [18-08:00]

Wells’ score

“The model should be applied only after a history and physical suggests that venous thromboembolism is a diagnostic possibility. it should not be applied to all patients with leg pain or swelling. This is the most common mistake made. Also, nev

er never do the D-dimer first [before history and physical exam]. The monster in the box is that the D-dimer is done first and is positive (as it is for many patients with non-VTE conditions) and then the physician assumes that VTE is now possible and then the model is done. Do the history and physical exam first and decide if VTE is a diagnostic possibility! Dr P Wells

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 (required whether Wells’ score high or low)

Actions

  1. Does the patient need an Ultrasound ? (Wells’ Actions)
    • Low Risk Wells’ (≤1) & Low Age Adjusted D-Dimer [500ng/ml (age≤50) OR 10ng/ml x Age (age>50)]
      • 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 Age Adjusted D-Dimer – Go to Step 2
  2. Exclusions to Outpatient/Ambulatory Pathway: > MAU/AMU
    • Unable to Go home and return for U/S
    • CKD 5 – Creatinine  Clearance <15 (eGFR <30 calculate CrCl – HERE)
    • Liver Failure
    • Bleed Risk (e.g. Oesophageal varices, major surgery, major trauma, intracranial bleed <4/52, grade 3 hypertensionetc.)
    • NSTEMI/Unstable angina
  3. Outpatient Pathway:
    • Order Lower leg Ultrasound: (Side, Wells’ and D-Dimer are required)
    • Treatment
      • First line – Rivaroxaban: 15mg BD 7 day
      • Second Line – Dalteparin – 7 day [Trust Guide] OR  [BNF]
        • First Line in Pregnancy/Lactating
    • Patient advice leaflet [PDF pg:2]
    • Give patient details to AAU/SDEC – for follow up
  4. Inpatient Pathway:

Pathway: HERE

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