Morning Report: 5/3/2012

Thanks to Dr. Pearsall for this review of the clinical pathways to diagnosis of lower extremity DVT!

Dx of Suspected 1^st 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, 9^th 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.

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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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