DVT, Acute Arterial Occlusion, PVD

DVT: (therapeutic INR: 2-3) (unilateral LE swolling, may be painful, may be red, may have cords, Hx of immobility – post-orthopedic surgery, long car ride or flights)

Confirm Dx: Order Venous Doppler US of bilateral LE

  1. Lovenox (therapeutic) 1mg/kg/dose SubQ q12 hours
  2. Coumadin 5mg PO qd (starting dose then follow INR and adjust accordingly)
    1. Coumadin PO for 6 months if 1st clot
    2. Coumadin PO for lifetime if multiple clots (also investigate why multiple clot formation: Factor V Leidan, anti-phospholipid antibody, etc.) – consider placing an IVC filter.
  3. Consider new alternatives to Coumadin (new anticoagulants): Xarelto (Rivaroxaban) 50 mg PO bid, Dabigatran (Pradaxa), Apixaban (Eliquis) (advantage: pt would not have to check INR)
    1. Ex: Start patient on Xarelto 15mg BID for 21 days, then change to Xarelto 20mg once daily for 90 days

If large DVT: Look for cellulitis, possible long term venous insufficiency (may need compression stockings): Post-Thrombotic Syndrome

Wells’ Criteria for DVT: http://www.mdcalc.com/wells-criteria-for-dvt/

Wells score or criteria: (possible score −2 to 9)

  1. Active cancer (treatment within last 6 months or palliative): +1 point
  2. Calf swelling ≥ 3 cm compared to asymptomatic calf (measured 10 cm below tibial tuberosity): +1 point
  3. Swollen unilateral superficial veins (non-varicose, in symptomatic leg): +1 point
  4. Unilateral pitting edema (in symptomatic leg): +1 point
  5. Previous documented DVT: +1 point
  6. Swelling of entire leg: +1 point
  7. Localized tenderness along the deep venous system: +1 point
  8. Paralysis, paresis, or recent cast immobilization of lower extremities: +1 point
  9. Recently bedridden ≥ 3 days, or major surgery requiring regional or general anesthetic in the past 12 weeks: +1 point
  10. Alternative diagnosis at least as likely: −2 points

Those with Wells scores of:

  • high if greater than two: (likelihood: 53% chance of having a DVT)
  • moderate if one or two: (likelihood: 17% chance of having a DVT)
  • low if less than one: (likelihood: 5% chance of having a DVT)

Other scoring system:

  • two or more have a 28% chance of having DVT.
  • lower score have 6% odds of having a DVT.

Acute Arterial Occlusion:

  • Sx: cold distal limb, delayed capillary refill, significant pulse deficits, pain, numbness
  • Cause: arterial thromboembolism (recent MI, Afib)
  • Tx: IV Heparin (immediately!!!) followed by continuous Heparin infusion
    1. Heparin: (if delayed -> loss of limb if severe ischemia!)
      1. Prevents further propagation of the thrombus
      2. Inhibits thrombosis distally in the arterial/venous systems due to low flow and stasis

Peripheral Arterial Disease (PAD):

S/Sx: Claudication, decreased exercise tolerance (can walk smaller distance before pain begins, relief with rest), non-palpable pedal pulses (use Doppler US to auscultate post tibial and distal pedal pulses), cold, shiny skin on shins with little to no hair follicles, toes may be turning purple/black (gangrene), induce claudication and paleness by raising leg up off bed that resolved when leg returned to rest, may even have ischemic pain at rest.

  • Heparin drip overnight 70U/kg/dose IV once (max: 10,000U) (high/standard dose/target)
    1. Stat PTT and PT/INR for heparin drip
  • Full dose Aspirin 325 mg PO (chewable) – upon admission. Continue low dose 81mg PO qd.
  • Consult vascular surgery (Dr. Rush, Dr. Hopkins, Dr. Yoon). Order ABI.
  • Pain control: Morphine IV (PRN vs. scheduled)
  • Consider co-morbid problems:
    1. CAD: coronary atherosclerosis: chest pain – r/o ACS:
      1. Serial Troponin and EKG X3, Consult cardio: Order Lexiscan stress test and 2D Echo.
    2. Hyperlipidemia: Order Lipid panel and calculate ASCVD. Start Lipitor.
    3. Smoking: Smoking cessation strongly encouraged. Avoid Nicotine patch initially b/c may negatively affect vasc surgery.
    4. HTN: Add Lisinopril.
    5. COPD: DuoNeb neb (scheduled q4-6 hr resp Tx) and Spiriva.
  • Long-term Tx:
    • 1) STOP smoking!
    • 2) Exercise – walk more.
    • 3) Antiplatelets (Aspirin, Cilostazol).

Leave a Reply

Your email address will not be published.