Non-Covid clinical crises: Adult DVT
Pulse’s series on how to manage non-Covid subacute problems when you’re out of your comfort zone and there’s minimal help available
This is designed to help in case the current pandemic has decimated your usual DVT management pathway but, where possible, aim to follow NICE December 2019 guidelines.
GPs should use their clinical judgement to determine whether investigations or referral are indicated.
If ultrasound is available then this should be requested, even if this takes some time to be performed. Evidence of a DVT will be detectable for some weeks to months after onset and will inform the need to continue anticoagulation treatment. Do not defer treatment pending the scan, treat empirically initially.
In these times, the 2-level Wells DVT score should generally be used first as it is a validated risk score for DVT. The risk of DVT is likely if the score is two points or more, and unlikely if the score is one point or less. If DVT is likely then an ultrasound should be requested.
If DVT is unlikely then D-dimer first, and ultrasound if D-dimer is positive. If it is not possible to arrange D-dimer testing, then exercise clinical judgement. Consider short course of subcutaneous fractionated heparin – which could be started in the surgery if held as a stock item - and review in 3-4 days, with repeat Wells Score.
There are more considerations with the use of DOAC such as dosing for renal impairment, irreversibility, increased risk of thrombosis with APS. If the Wells score is low, then a low-risk strategy is best.
D-dimer is unreliable in pregnant and postpartum women and should not be used.
In patients in whom DVT is likely, commence apixaban or rivaroxaban immediately. Plan to continue for three months minimum.
Compression stockings, while not indicated to prevent post-thrombotic syndrome, can be helpful in acute symptom relief and should be considered.
In the event of severe symptoms of limb swelling, pain or venous congestion within 4 weeks of onset of DVT, contact local vascular service without delay to discuss suitability for thrombolysis
In pregnant and postpartum women, commence LMWH immediately and refer for investigation.
Investigate for underlying causes of DVT such as cancer, if DVT is unprovoked as far as you can in the current environment.
Mr Dominic Dodd is a consultant vascular surgeon at the Varicose Vein Treatment Centre