Updated: 3/16/2020

Deep Venous Thrombosis

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Snapshot
  • A 45-year-old woman presents to the emergency room for pain in her left calf. She reports flying back to the United States from Australia 2 days ago. Her flight was nonstop, making it a > 12-hour flight. She states having not worn any compression stockings and notes some swelling in the lower extremities bilaterally after the flight. She has a past medical history of hypertension and diabetes and currently takes oral contraceptive pills. Her vital signs are normal. On physical exam, her left calf is 2 cm larger in circumference than her right calf. It is also erythematous and warm with pitting edema. Her D-dimer levels are elevated.
Introduction
  • Clinical definition
    • blood clot in the deep veins, typically of the lower extremities
  • Epidemiology
    • incidence
      • increases with age
    • location
      • lower extremities
    • risk factors
      • immobility
      • hospitalization
      • surgery
      • thrombophilia
      • malignancy
      • trauma
      • state of elevated estrogen
  • Pathogenesis
    • Virchow triad puts patients at risk for DVTs
      • venous stasis
        • e.g., from long trips or bed rest
      • hypercoagulability
        • e.g., from malignancy or oral contraceptives
      • endothelial damage
        • exposed collagen will trigger the clotting cascade
        • usually secondary to lower limb trauma
  • Associated conditions
    • pulmonary embolism
Presentation
  • Symptoms
    • lower extremity pain and swelling
  • Physical exam
    • examination of the affected extremity
      • redness
      • warmth
      • Homan sign
        • calf tenderness with passive dorsiflexion of the foot
        • however, this is not a very useful sign
    • shortness of breath
      • may indicate pulmonary embolism
Imaging
  • Compression ultrasound with Doppler
    • indications
      • all patients
      • diagnostic gold standard
    • findings
      • clot formation in deep venous system
Studies
  • Labs
    • D-dimer
      • high sensitivity
      • low specificity
      • often used to rule out DVT
  • Making the diagnosis
    • based on clinical presentation and imaging
Differential
  • Cellulitis
    • distinguishing factors
      • no clot found on ultrasound
      • patients may have systemic signs, such as a fever
      • D-dimer is negative
Treatment
  • Management approach
    • most patients undergo anticoagulation for 3-6 months
    • however, if the DVT is unprovoked with no identifiable cause, or if risk factors are persistent, patients may require longer periods of anticoagulation for prophylaxis of future DVTs
  • Conservative
    • appropriate prophylaxis
      • indication
        • all patients at risk for DVTs
      • modalities
        • compression stockings for long flights
        • frequent ambulation
  • Medical
    • direct oral anticoagulants
      • drugs
        • rivaroxaban 
        • apixaban
      • indication
        • for outpatient management
        • useful given once/day dosing and no monitoring 
    • low-molecular-weight heparin (LMWH)
      • indications
        • initial therapy
        • patients with normal renal function 
    • unfractionated heparin
      • indication
        • initial therapy
        • patients with contraindications to LMWH
        • can be used as "bridge" to therapeutic warfarin dose
        • appropriate if > 72 hours after recent surgery
    • warfarin
      • indications
        • long-term anticoagulation 
  • Operative
    • inferior vena cava (IVC) filter placement
      • indication
        • patients with contraindications to anticoagulation
Complications
  • Pulmonary embolism
 

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Questions (5)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.CV.16.39) A 63-year-old male with a history of type II diabetes, hypertension, and chronic kidney disease (CKD) stage IV presents to his primary care physician complaining of new onset swelling and calf tenderness in his right lower extremity. The patient has just returned from a trip to Europe for work. Examination of the extremity is shown in Figure A. The patient is referred to the Emergency Department, where he undergoes a right lower extremity duplex ultrasound shown in Figure B. Laboratory values are shown in Figure C. What is the next best step in management? Review Topic | Tested Concept

QID: 104679
FIGURES:
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Treatment with unfractionated heparin

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Initiate warfarin therapy

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Aspirin and clopidogrel therapy

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Treatment with low molecular weight heparin

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Placement of an inferior vena cava filter

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(M3.CV.15.43) A 46-year-old woman presents to the emergency department with 1 day of painful leg swelling. She is otherwise healthy and takes only oral contraceptive pills. The patient does not regularly follow up with her primary doctor and is generally not medically compliant. Her temperature is 98.0°F (36.7°C), blood pressure is 122/78 mm Hg, pulse is 70/min, respirations are 13/min, and oxygen saturation is 99% on room air. Lower extremity examination shows mild calf swelling on her left leg, but otherwise is unremarkable. An ultrasound is performed as seen in Figure A. Which of the following is the most appropriate course of action? Review Topic | Tested Concept

QID: 103334
FIGURES:
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Alteplase

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Heparin

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Observation

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Rivaroxaban

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Warfarin

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(M2.CV.14.41) A 62-year-old Nigerian woman arrived 2 days ago to the US to visit her adult children from Nigeria. She is now brought to an urgent care center by her daughter for leg pain. Her right leg has been painful for 24 hours and is now causing her to limp. She denies any fevers, chills, or sweats and does not remember injuring her leg. She tells you she takes medications for hypertension and diabetes and occasionally for exertional chest pain. She has not had any recent chest pain. The right leg is swollen and tender. Flexion of the right ankle causes a worsening of the pain. Doppler ultrasonography reveals a large clot in a deep vein. Which of the following is the most appropriate course of action? Review Topic | Tested Concept

QID: 104047
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Serologic tests for hypercoagulability

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Initiation of warfarin

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Initiation of heparin

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Treatment with tissue plasminogen activator

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Initiation of heparin followed by bridge to warfarin

67%

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