Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Calculate Wells; use D-dimer for low probability; obtain ultrasound for intermediate/high.
- Start anticoagulation unless contraindicated; select regimen and duration based on provoking factors.
- Plan secondary prevention; address cancer screening and thrombophilia as indicated.
Clinical Synopsis & Reasoning
Evaluate suspected DVT using Wells score and D-dimer in low probability cases. Confirm with compression ultrasonography. Start anticoagulation with DOACs or LMWH/warfarin; determine duration based on provoked vs unprovoked events and bleeding risk.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|
| Wells score and D-dimer | Pretest probability | Rule-out in low probability | — |
| Compression ultrasound (proximal ± whole-leg) | Diagnosis | Noncompressible vein | Gold standard in ED |
| Cancer/Thrombophilia evaluation (selected) | Etiology | Unprovoked or recurrent VTE | Targeted workup |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| Phlegmasia | Threatened limb | Urgent IR/surgical consult |
| Active cancer/recurrent VTE | Long-term risk | Extended anticoagulation |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Apixaban/Rivaroxaban (preferred) | DOACs | Hours | Outpatient-friendly regimens | Renal dosing applies |
| LMWH bridge → Warfarin (selected) | Vitamin K antagonist | Days | Mechanical valves/antiphospholipid syndrome | INR 2–3 |
| Thrombolysis/thrombectomy (iliofemoral/phlegmasia) | Interventional | Hours | Selected severe cases | Specialist centers |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- ACCP/ESC VTE guidance — Link