Signs and Symps
No single feature is diagnostic:
- Single limb oedema – Most specific
- Leg pain – 50% but is nonspecific
- Calf pain on dorsiflexion of the foot (Homan’s sign)
- Tenderness of deep veins – 75% of patients
- Warmth AND/OR erythema (although blanching is possible)
- A palpable, indurated, cordlike, tender subcutaneous venous segment
Management [08-18:00]
- Senior Triage in A&E : Middle grade/Consultant physician OR Band 7 sister or above
- Suspicion of DVT (Deep Vein Thrombosis)
- Alternative Red-Flag diagnosis ruled out: Cellulitis, Ischaemic limb, MSK, Phlegmasia Cerulea/Alba Dolens
- No AAU/SDEC exclusions: NEWS2 >4, New Oxygen Requirement, New/Acute Confusion
All of above – refer straight to AAU/SDEC
Management [18-08:00]
- Suspicion of DVT (Deep Vein Thrombosis)
- Alternative Red-Flag diagnosis ruled out: Cellulitis, Ischaemic limb, MSK, Phlegmasia Cerulea/Alba Dolens
Wells’ score
“The model should be applied only after a history and physical suggests that venous thromboembolism is a diagnostic possibility. it should not be applied to all patients with leg pain or swelling. This is the most common mistake made. Also, nev
er never do the D-dimer first [before history and physical exam]. The monster in the box is that the D-dimer is done first and is positive (as it is for many patients with non-VTE conditions) and then the physician assumes that VTE is now possible and then the model is done. Do the history and physical exam first and decide if VTE is a diagnostic possibility!“ Dr P Wells
| Feature | Score |
|---|---|
| Entire Leg swollen | +1 |
| Tender over deep veins | +1 |
| Pitting oedema (greater in symptomatic leg) | +1 |
| Immobilisation of limb | +1 |
| Previous DVT/PE | +1 |
| Active Cancer | +1 |
| Bed Ridden (>3 days within last 4 weeks) | +1 |
| Collateral superficial veins (non-varicose) | +1 |
| Calf swelling >3cm (in symptomatic leg) | +1 |
| Alternative diagnosis (equally or more likely than DVT) | -2 |
Investigations
- FBC
- Renal function
- Liver function
- CRP
- Clotting
- D-Dimer (required whether Wells’ score high or low)
Actions
- Does the patient need an Ultrasound ? (Wells’ Actions)
- Low Risk Wells’ (≤1) & Low Age Adjusted D-Dimer [500ng/ml (age≤50) OR 10ng/ml x Age (age>50)]
- No further investigation required (Remember: it is known there are DVT’s in this group but they don’t progress to become an issue, if they represent reconsider diagnosis)
- High Risk Wells’ (≥2) OR Low Risk and High Age Adjusted D-Dimer – Go to Step 2
- Low Risk Wells’ (≤1) & Low Age Adjusted D-Dimer [500ng/ml (age≤50) OR 10ng/ml x Age (age>50)]
- Exclusions to Outpatient/Ambulatory Pathway: > MAU/AMU
- Unable to Go home and return for U/S
- CKD 5 – Creatinine Clearance <15 (eGFR <30 calculate CrCl – HERE)
- Liver Failure
- Bleed Risk (e.g. Oesophageal varices, major surgery, major trauma, intracranial bleed <4/52, grade 3 hypertensionetc.)
- NSTEMI/Unstable angina
- Outpatient Pathway:
- Order Lower leg Ultrasound: (Side, Wells’ and D-Dimer are required)
- Treatment
- First line – Apixaban – 7 day
- Second Line – Tinzaparin – 7 day OR [BNF]
- First Line in Pregnancy/Lactating (use booking weight to calculate dose in pregnancy)
- Patient advice leaflet [PDF pg:2]
- Give patient details to AAU/SDEC – for follow up
- Inpatient Pathway:
- Commence Tinzaparin – if not contraindicated; [BNF]
- Ref to AMU/MAU
