DVT complete diagnostic approach resident survival guide: Difference between revisions
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==Complete Diagnostic Approach== | ==Complete Diagnostic Approach== | ||
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid22315267">{{cite journal| author=Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells PS, Stevenson MD et al.| title=Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e351S-418S | pmid=22315267 | doi=10.1378/chest.11-2299 | pmc=PMC3278048 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315267 }} </ref> | A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid22315267">{{cite journal| author=Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells PS, Stevenson MD et al.| title=Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e351S-418S | pmid=22315267 | doi=10.1378/chest.11-2299 | pmc=PMC3278048 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315267 }} </ref> | ||
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* 7.5 mg daily | * 7.5 mg daily | ||
* 10 mg daily if weight>100 Kg<ref name="pmid22315259">{{cite journal| author=Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ et al.| title=Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e152S-84S | pmid=22315259 | doi=10.1378/chest.11-2295 | pmc=PMC3278055 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315259 }} </ref> | * 10 mg daily if weight>100 Kg<ref name="pmid22315259">{{cite journal| author=Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ et al.| title=Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e152S-84S | pmid=22315259 | doi=10.1378/chest.11-2295 | pmc=PMC3278055 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315259 }} </ref> | ||
Revision as of 00:45, 27 May 2014
Complete Diagnostic Approach
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[1]
Identify possible precipitating factors: Obtain a detailed history:
❑ Past medical history:
❑ History of thrombophilia
❑ Abortion at second or third trimester of pregnancy (suggestive of an inherited thrombophilia or APS) | |||||||||||||||||||||||||||||
❑ Examine the patient: Extremities
❑ Homan's sign: tenderness upon dorsiflexion of the foot (not reliable)
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Consider alternative diagnoses: ❑ Muscle strain or muscle tear | |||||||||||||||||||||||||||||
Is the suspected DVT a first or a recurrent episode? | |||||||||||||||||||||||||||||
First suspected episode | Suspected recurrent episode | ||||||||||||||||||||||||||||
Low pretest probability (Click here for the diagnostic approach) | Moderate pretest probability (Click here for the diagnostic approach) | High pretest probability (Click here for the diagnostic approach) | |||||||||||||||||||||||||||
Initial Anticoagulation Choices (DVT)
❑ SC low molecular weight heparin (1st line)
- ❑ Enoxaparin 1.0 mg/kg every 12 hours OR 1.5 mg/kg once daily
- ❑ Tinzaparin 175 U/kg once daily
❑ SC fondaparinux (1st line)
- ❑ 5 mg once daily (if body weight <50 kg)
- ❑ 7.5 mg once daily (if body weight <50-100 kg)
- ❑ 10 mg once daily (if body weight >100 kg)
- ❑ 80 U/kg as bolus, followed by 18 U/kg/h, OR
- ❑ 70 U/kg as bolus, followed by 15 U/kg/h for stroke or cardiac patients[2]
- ❑ Adjust the dosages according to the aPTT
- ❑ 333 U/kg as bolus, followed by 250 U/kg[2]
Anticoagulation for VTE
Warfarin
- Begin with 10 mg warfarin for 2 days followed by dosing based on the INR
- Start at the 1st or 2nd day of the initial parenteral therapy
- Target INR is 2-3
- Monitor INR:
- If stable, repeat INR every 12 weeks
- If stable but one value 0.5 below or above the target range, continue the same dose and repeat INR within 1-2 weeks
- Avoid NSAIDs, COX2 selective NSAIDs and some antibiotics[2]
Heparin
IV-UFH
- 80 U/kg as bolus, followed by 18 U/kg/h
- 70 U/kg as bolus, followed by 15 U/kg/h for stroke or cardiac patients[2]
SC-UFH
- 333 U/kg as bolus, followed by 250 U/kg[2]
LMWH: decrease dose in renal insufficiency (Creatinine clearance < 30 mL/min)[2]
Fondaparinux
- 7.5 mg daily
- 10 mg daily if weight>100 Kg[2]
- ↑ Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells PS, Stevenson MD; et al. (2012). "Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e351S–418S. doi:10.1378/chest.11-2299. PMC 3278048. PMID 22315267.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ; et al. (2012). "Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e152S–84S. doi:10.1378/chest.11-2295. PMC 3278055. PMID 22315259.