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Deep Vein Thrombosis - Coggle Diagram
Deep Vein Thrombosis
Recently bedridden for 3 days or more, or major surgery within the last 12 week requiring general or regional anaesthesia
Localized tenderness along the distribution of the deep venous system (such as the back of the calf)
Paralysis, paresis, or recent plaster immobilization of the legs.
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When to suspect
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Skin changes, which include oedema, redness and warmth
Calf swelling (more rarely, swelling of the entire leg)
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Assess leg/thigh swelling. Measure circumference of the leg 10cm below tibial tuberosity and compare with asymptomatic leg - difference of more than 3cm increases the probability of DVT diagnosis
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Management
If starting interim anticoagulation therapy: obtain baseline blood tests including full blood count, renal and hepatic function, prothrombin time (PT) and activated partial thromboplastin time (APTT) - do not wait for results, review/act on results of baseline drugs within 24 hours of starting interim therapeutic anticoagulation therapy.
Follow up - if no contraindications those with DVT will require maintenance treatment of oral anticoagulation following acute treatment. - Specialists will make clinical decisions of choice of anticoagulant/duration of treatment. Treatment usually for at least 3 months.
Interim therapeutic anticoagulation: offer apixaban or rivaroxaban first line (considering contraindications dependent on the individual comorbidities, contraindications and the persons preference). Consider a therapy which can be continued if required.
If unprovoked DVT ensure person is investigated for possibility of undiagnosed cancer and offer thrombophilia testing (if appropriate)
Unlikely DVT - D-dimer test with results within 4 hours if results not able to be obtained in 4 hours offer interim therapeutic anticoagulation. If positive - arrange proximal leg vein ultrasound. If negative - stop therapeutic anticoagulation and consider alternative diagnosis.
Advise on: how to take anticoagulatants, duration of treatment and monitoring requirements, possible adverse effects and interactions, how it may affect dental treatment, risks associated with extended travel, when and how to seek medical help. Do not offer elastic graduated compression stockings to prevent post-thrombotic syndrome or VTE recurrence.
Likely DVT dependent on score - Refer to HOT clinic - leg ultrasound, d-dimer test, interim therapeutic anticoagulation with ultrasound results within 24 hours.
Refer immediately for same-day assessment and management if DVT is suspected in a women who is pregnant or has given birth within the last 6 months. For all others with suspected use DVT Well's Score
Differential Diagnosi
Cardiovascular disorders: superficial thrombophlebitis, post-thrombotic syndrome, venous obstruction or insufficiency or external compression of major veins, acute arterial ischaemia, vasculitis, heart failure.
Other conditions: Ruptured Baker's cyst, cellulitis, dependent oedema, lymphatic obstruction, septic arthritis, cirrhosis, nephrotic syndrome and compartment syndrome.
Physical trauma - calf muscle tear/Achilles' tendon tear, calf muscle haematoma, fracture.
Definition: DVT is the formation of a blood clot in a deep vein which partially or completely obstructs blood flow. Thrombus can dislodge and travel in the blood, commonly to the pulmonary arteries, known as a pulmonary embolism (PE). Provoked DVT - transient risk factors, Unprovoked DVT occurring the absence of transient risk factors.