DVT: Approach and management in the ED

Well's scoring / criteria

Present	Score
Paralysis, paresis or immobilisation in a plaster cast	+1
Bed ridden (> 3/7) or surgery within 4/52	+1
Tenderness along line of femoral or popliteal veins (NOT just calf tenderness)	+1
Entire limb swollen	+1
Calf >3cm bigger circumference, 10cm below tibial tuberosity	+1
Pitting oedema greater in symptomatic limb	+1
Dilated collateral superficial veins (on-varicose)	+1
Past Hx of confirmed DVT	+1
Malignancy (incl. treatment within 6 months)	+1
Alternative Dx is more likely than DVT	-2

Rivaroxaban Special populations

Renal impairment

Xarelto is to be used with caution in these patients
Please check BNF or medicines.ie

Hepatic impairment

Rivaroxaban is contraindicated in patients with hepatic disease associated with coagulopathy and clinically relevant bleeding risk including cirrhotic patients with Child Pugh B and C.

Elderly population

No dose adjustment

Body weight

No dose adjustment

Gender

No dose adjustment

Children

Xarelto is not recommended for patients <18 years

DDx

Baker's cyst
Cellulitis
Superficial venous thrombosis
Popliteal art pathology
Inguinal lymphadenopathy/proximal mass
External venous compression
Post-phlebitic (-thrombotic) syndrome
Proximal abscess (esp. in IVDU)
Gout
Lymphoedema
Oedema of cardiac/hepatic/renal failure
Trauma (e.g. muscle injury, fracture)

Not suitable for home treatment

Unable to walk, frail or in severe pain
Unable to understand the instructions
Unable to understand the importance of compliance with the treatment
Unable to return for the scan next morning - if awaiting scan

Bleeding risk:

Liver disease
Active peptic ulcer
Alcohol abuse

Management Proven VTE

Provoked leg DVT

Anticoagulate for 3 months.

Unprovoked DVT

Increased risk of occult malignancy so:

Ask about personal or FHx of malignancy and symptoms concerning for underlying malignancy e.g. weight loss, bleeding, altered bowel habit etc
A thorough physical exam: including breast and PR
Ensure age appropriate screening is up to date
Check FBC, ESR, LFT, U&E, CXR, Ca⁺⁺, urinalysis and CXR
Men > 40 - request PSA
The need for further investigation (endoscopy, imaging etc.) should be guided by findings from the history and exam and results from the initial blood tests (ISTH 2017, NICE 2020)
For those already antiocaogulated, who develop a DVT, please discuss with haematology re home management (haematology follow up) with therapeutic LMWH

Isolated calf DVT

For high risk (e.g. cancer) patients, or very symptomatic patients, - treat with Rivaroxaban 15mg bd po day 1-21 then Rivaroxaban 20mg od po day 22+) for 3 months.

For low risk patients who are mildly sympomatic, please discuss with the patient. Anticoagulation reduces the incidence of clot propagation, clot recurrence (3% vs. 9% Cochrane [below] NNT = 16) and the need for re-scan but increases the risk of bleeding and means taking tablets each day for 3 months. Anticoagulation does not reduce the incidence of PE with isolated calf DVT.

If you and the patient jointly decide to not anticoagulate, please ask the patient to return for a rescan in 1-2 weeks (15% propagate).

Thrombophilia screen in OPD, not ED

In CUH, a thrombophilia screen may be requested by the haematology team using a specific consent form (print version on https://www.cuh.hse.ie/our-services/our-specialities-a-z-/laboratory-medicine/services-provided/downloads/cuh-thrombophilia-screen-request-form.pdf).

Considered in those

Patients with a known FHx of thrombophilia
Under 45 years old with VTE, no ppt cause
Recurrent thromboses
Thrombosis in an unusual site
FHx of thrombosis or
FHx of recurrent (2 or more) VTE
Past Hx of of recurrent foetal loss

Request

Antithrombin
Protein S, Protein C
APC resistance
Factor V Leiden mutation
Lupus anticoagulant
Anticardiolipin antibodies

Br J Haematol 2010: 149 (2) 209-220 Clinical guidelines for testing for heritable thrombophilia (www.bcshguidelines.com)

DVT