Thanks to Dr. Pearsall for this review of the clinical pathways to diagnosis of lower extremity DVT!
Dx of Suspected 1st LE DVT
Tools to Dx DVT:
- Wells Prediction Rules
- D-dimer
- 2-point proximal compression US
- Whole leg doppler
- Venography
Basic Pathway to Dx:
- Determine pretest probability
- Use modalities: based on recent recommendations by American College of Chest Physicians in Executive Summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed. (Remember that email Dr. Sinert sent out!)
Low pretest probability:
- Mod/highly sensitive D-dimer or prox CUS (preferably D-dimer)
- D-dimer or prox US neg, then stop
- If positive D-dimer, then prox CUS
Mod pretest probability:
- Highly sensitive D-dimer or prox CUS or whole leg Doppler
- Negative D-dimer, then stop
- If pos D-dimer, then prox CUS or whole leg Doppler
- If initial prox CUS neg, then repeat in 1 week or do mod/high sensitive D-dimer
- If neg serial prox CUS, neg single prox CUS + neg D-dimer, then stop
- If whole leg Doppler neg, then stop
- If isolated distal DVT, then serial US to r/o proximal extension
High pretest probability:
- Prox CUS or whole leg Doppler
- If neg prox CUS, then highly sensitive D-dimer or whole leg Doppler or repeat prox CUS in 1 week (preferably D-dimer)
- Single neg prox CUS and pos D-dimer, then whole leg Doppler or repeat prox CUS in 1 week
- If neg serial prox CUS, neg single prox CUS + neg D-dimer or neg whole leg Doppler, then stop
- If isolated distal DVT, then serial US to r/o proximal extension
** Keep in mind to always use clinical judgment… and opinions vary.
The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.
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Jay Khadpe MD
Editor in Chief of "The Original Kings of County"
Assistant Professor of Emergency Medicine
Assistant Residency Director
SUNY Downstate / Kings County Hospital
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