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<< Deep Venous Thrombosis: Identifying The Killer Before It Strikes
Disposition
It is still common practice to admit most patients with DVT, but this is regionally dependent. In some locales almost all patients are treated as outpatients, and they are sent home after a dose of low-molecular-weight heparin. For the next day’s treatment, specialized nurses train patients to administer the low-molecular-weight heparin and instruct them as to which conditions must prompt a return to the ED. In these areas, the local pharmacies stock low-molecular-weight heparin and syringes. But in other locales, all DVT patients are admitted for intravenous heparin, and no pharmacy chains carry low-molecular-weight heparin.
While it may be safe and effective to treat stable and reliable patients with DVT at home, it may not always be feasible. The individual physician must ensure that appropriate training and follow-up can be guaranteed for the next day, if the ED is not capable of providing such training. Further, patients must be able to obtain not only the low-molecular-weight heparin they need, but the ancillary supplies, as well. For patients with limited financial resources or no health insurance, one must assure that they will be able to afford everything they are prescribed — plus they will need to obtain warfarin, get regular INR checks, and in general have access to the health care system.
Patients who are sent home after a negative duplex ultrasound should have a repeat ultrasound examination in 5 to 7 days. This is recommended to uncover any calf DVTs that are progressing to become proximal DVTs. This schedule of repeat scanning is well established and is quite an improvement from original recommendations that seemed to suggest repeat scans every 2 or 3 days, out to 2 weeks. Patients who are low-risk, have a negative duplex ultrasound, and a negative (reliable) D-dimer do not require any further ultrasound examination, unless the concern for DVT otherwise increases (eg, worsening symptoms).
Patients who are discharged after a dose of low-molecular- weight heparin, with the intention of having an outpatient duplex ultrasound examination the next day, should be instructed to return to the ED if they have any difficulty in obtaining the test the next morning, or if they have symptoms, such as shortness of breath, chest pain, or worsening leg symptoms. No prospective study has yet compared this strategy to keeping patients in the ED overnight under observation.
While it may be safe and effective to treat stable and reliable patients with DVT at home, it may not always be feasible. The individual physician must ensure that appropriate training and follow-up can be guaranteed for the next day, if the ED is not capable of providing such training. Further, patients must be able to obtain not only the low-molecular-weight heparin they need, but the ancillary supplies, as well. For patients with limited financial resources or no health insurance, one must assure that they will be able to afford everything they are prescribed — plus they will need to obtain warfarin, get regular INR checks, and in general have access to the health care system.
Patients who are sent home after a negative duplex ultrasound should have a repeat ultrasound examination in 5 to 7 days. This is recommended to uncover any calf DVTs that are progressing to become proximal DVTs. This schedule of repeat scanning is well established and is quite an improvement from original recommendations that seemed to suggest repeat scans every 2 or 3 days, out to 2 weeks. Patients who are low-risk, have a negative duplex ultrasound, and a negative (reliable) D-dimer do not require any further ultrasound examination, unless the concern for DVT otherwise increases (eg, worsening symptoms).
Patients who are discharged after a dose of low-molecular- weight heparin, with the intention of having an outpatient duplex ultrasound examination the next day, should be instructed to return to the ED if they have any difficulty in obtaining the test the next morning, or if they have symptoms, such as shortness of breath, chest pain, or worsening leg symptoms. No prospective study has yet compared this strategy to keeping patients in the ED overnight under observation.
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