Deep vein thrombosis: Clinical sciences

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An 81-year-old man is admitted to the hospital for an acute diverticular bleed. He receives IV fluid resuscitation and 2 units of packed red blood cells. Abdominal CT scan is performed, and is indicative of diverticulosis at the splenic flexure. He has another bloody bowel movement on day 3 of his hospital stay, but his hemoglobin and symptoms remain stable. On examination he is noted to have swelling and erythema of the right leg. Temperature is 37.3 °C (99.1 °F), blood pressure is 130/82 mmHg, pulse is 88/min, respiratory rate is 14/min, and oxygen saturation is 98% on room air. On physical examination, there is pitting edema and warmth of the right leg, and pain with passive dorsiflexion of the right foot. An ultrasound shows a non-compressible right popliteal vein. Laboratory studies are shown below. Which of the following is the next best step in management?
 
Laboratory value
Result
Leukocyte count  
9000/mm3   
Hemoglobin
7.2 g/dL  
Platelet count  
160,000/mm3   
INR
1.0  
D-dimer
1500 ng/mL  

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Deep vein thrombosis, or DVT, is a blood clot that develops in the deep veins, most commonly of the lower limbs. Less commonly, DVT can form in the deep veins of the arms or mesenteric veins of the bowel.

The pathogenesis of DVT centers around the Virchow triad, which includes venous stasis, hypercoagulability, and endothelial injury.

If untreated, the thrombus can lead to limb ischemia, hemodynamic instability, pulmonary embolism, and even death.

Now, if your patient presents with signs and symptoms suggestive of DVT, first you should perform an ABCDE assessment to determine if your patient is unstable or stable. If the patient is unstable, stabilize the airway, breathing, and circulation. Next, obtain IV access and start continuous vital sign monitoring, including pulse oximetry, blood pressure, and heart rate. If needed, provide supplemental oxygen to maintain the oxygen saturation above 92%.

Alright, now let’s go back to the ABCDE assessment and discuss how to manage stable individuals. First, obtain a focused history and physical examination. History usually reveals pain, swelling, and warmth in the affected limb as well as DVT risk factors,

such as age above 65, recent surgery, prolonged immobilization, and active cancer, as well as smoking and obesity.

Also keep in mind that estrogen increases the risk of venous thrombosis, so pregnancy and the use of oral contraceptives are also important risk factors.

Finally, a family history of DVT can indicate a familial inheritance of genetic conditions predisposing to DVT, such as Factor V Leiden mutation.

On the other hand, the physical examination usually reveals edema, erythema, warmth, and tenderness of the affected area.

Sources

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  2. "American Society of Hematology 2020 Guidelines for Management of Venous Thromboembolism: Treatment of Deep Vein Thrombosis and Pulmonary Embolism. " Blood Adv. 2020;4:4693-4738.
  3. "NICE guideline: management of venous thromboembolic diseases and role of thrombophilia testing" Thorax (2012)
  4. "Diagnosis of DVT" Chest (2012)
  5. "Deep vein thrombosis: update on diagnosis and management.. " Med J Aust (2019;210(11):516-524.)
  6. "Venous thromboembolism: advances in diagnosis and treatment. " JAMA. (2018;320(15):1583-1594.)
  7. "The Use of Point-of-Care Ultrasound (POCUS) in the Diagnosis of Deep Vein Thrombosis" Journal of Clinical Medicine (2021)
  8. "Post-thrombotic syndrome–a position paper from European Society of Vascular Medicine. 1:10." Vasa ( 2021)
  9. "Evaluation of D-Dimer in the Diagnosis of Suspected Deep-Vein Thrombosis" New England Journal of Medicine (2003)