This document presents information on two patient cases of deep vein thrombosis (DVT). The first case describes a 67-year-old male with left lower limb swelling and pain for 5-6 days who was found to have DVT in the distal superficial femoral vein and popliteal vein based on a Doppler ultrasound. The second case describes a 45-year-old male with right lower limb swelling and pain for 4 days who had a history of left nephrectomy and was also found to have DVT based on a Doppler ultrasound. Both patients were started on anticoagulation therapy.

1. Deep Vein Thrombosis
Dr Mahmood
Emergency Medicine Resident
MEM

2.  A 67 old male patient presented with c/o painful swelling of left lower
limb since 5-6 days
 h/o trauma to left lower limb 3 days back
 Past history: nil
 No H/o: chest pain, SOB
 General examination:
-PR: 82/mins -RR:20/mins -Bp: 130/90mmhg
-Sp02: 98% on RA
 Systemic examination:
-RS: bilateral air entry
-CVS: s1+, s2+
-P/A: soft. BS+
L/E: swelling of left lower limb foot to thigh, tenderness +,
movements+, peripheral pulses+

3.  CBP: normal,
 TLC: 17,000
 Bleeding time and clotting time : normal
 2D-echo:
-no RWMA,
-good LV function ,
-IVC collapsing
 Color Doppler of venous system of left lower limb
performed
-Impression: intramural echogenic contents with absent
color flow uptake in distal SFV and popliteal vein s/o DVT

4.  A 45 years old male patient presented with complaints of right
lower limb painful swelling since 4 days.
- Sudden onset,
- Increasing gradually
- Sever cramping pain in calf and thigh
- increased on walking and movement of the limb
 h/o left sided nephrectomy 5 days back for left side renal cell carcinoma
(RCC)
 h/o chronic tobacco chewing
 No h/o of chest pan , SOB , abdomen pain
 No family history of VTE

5.  General examination:
-PR: 92/mins
-Bp: 140/90mmhg
-RR:20/mins
-Sp02: 98% on RA
 Systemic examination:
-RS: bilateral air entry
-CVS: s1+, s2+
-P/A: soft. BS+, scar of nephrectomy is seen over left lumbar
L/E: Swelling and redness over right lower limb from foot to thigh,
no dilated , engorged veins , skin is stretched and shiny

6.  Duplex ultrasound:
Impression: Common femoral ,deep femoral,
popliteal and posterior tibial vein show echogenic
thrombus and absent flow . s/o DVT
 2D-echo:
-no RWMA,
-good LV function ,
-IVC collapsing

7.  Surgical Management:
- Debridment of wound + IVC filter placement done
 Medical management :
-Tab ciplox (ciprofloxacin) 500 mg bd
-Tab ultracet (paracetamol+ tramadol) 1 tab bd
-Tab bevon tab od
-Tab pradaxa (dabigatran)150mg bd x 1month
-Tab dolo (paracetamol) 650 tid
 Advise:
-Left lower limb elevation
-High protein diet

8.  Introduction
 Etiology
 Risk factors
 Clinical features
 Complications
 Diagnostic procedures
 Management
 Prevention
 Differentials
 References

9.  Deep vein thrombosis (DVT) is the formation
of a blood clot in a deep vein most
commonly seen n the legs or in the arms

11.  Provoked DVT:
DVT where there is an identifiable risk factor
that likely caused the DVT.
 Unprovoked DVT:
DVT where there is no identifiable risk factor
that likely caused the DVT

12.  DVT usually originates in the lower extremity
venous system, starting at the calf and
progressing proximally to involve popliteal,
femoral or iliac system
 80-90% pulmonary emboli originates here

13.  An intimal defect often works as nidus for
clot formation
 Initially a platelet aggregate develops,
subsequently clotting factors through intrinsic
and extrinsic pathway fibrin and red cells
form a mesh until the lumen clot occludes
the vein wall.

17.  Age: incidence increase with advancing age
 Obesity: > BMI > is DVT
 Prolonged bed rest ( 4days or more)
 Lower limb fracture: a cast on the leg
 limb paralysis
 Extended travel (>4 hours)

18.  Acquired:
- Surgery and trauma are responsible for upto
40% of all thromboembolic disease
- Malignancy
- Hormonal therapy, OCP
- Pregnancy
- Nephrotic syndrome
- Antiphospholipid antibody syndrome
- SLE, IBD

19.  Inherited :
- Factor V Leiden mutation
- Antithrombin deficiency
- Protein C, S deficiency
- Prothrombin 20210 gene variant
- Homocysteinemia

20.  Trauma
 Surgery
 Peripheral and central lines

22.  Calf pain or tenderness or both
 Swelling wit pitting edema
 Increase in local temperature
 Redness or discoloration
 Dilatation of superficial veins

24.  Less frequent manifestations of DVT
includes
 Phlegmasia cerulea dolens
 Phlegmasia alba dolens
 Venous gangrene

25.  Extensive DVT of the major axial deep
venous channels of the lower extremity with
relative sparing if collateral veins
 The leg becomes blue in color, swollen and
painful
 Which may result in venous gangrene.

27.  When the thrombosis extends to the
collateral veins, massive fluid sequestration
and significant edema
 a/k/a Milk leg or white leg
 The leg is pale and cold, secondary to
arterial insufficiency,
 Extremely tender

29.  Homan’s sign:
- Pain in the calf region or knee with forced
dorsiflexion

30.  Moses / Bancroft’s sign:
- Gentle squeezing of the lower part of the calf from
- side to side causes sever pain
 Lowenberg sign:
- Pain is elicited rapidly when a blood pressure cuff is placed
and around the calf and inflated to 80mmhg

33.  Clinical examination alone is able to confirm
only 20-30%cases of DVT
 Blood test :
- D-Dimer test
- Coagulation profile
- Routine hematological investigation
 Imaging studies
 ECG and 2D echo

34.  D-dimer:
- D- dimer is a degradation product of fibrin cross-linking
- And elevated D- dimer level can occur when blood clots
are being formed. It can also be elevated in other
conditions unrelated to DVT (cancer, pregnancy, recent
surgery)
- The cutoff value for normal D-dimer is <500mcg/L

36.  Non invasive:
- Duplex ultrasound
- Plethysmography
- MRI techniques

37. Invasive:
- Venography
- Radio labeled fibrinogen

39.  Indications:
 When anticoagulant therapy is ineffective
 Unsafe
 Contraindicated
 The major surgical procedures for DVT are clot
removal and partial interruption of the inferior
vena cava to prevent pulmonary embolism.

40.  Inferior vena cave filter: it’s a type of vascular
filter into inferior vena cava to prevent life-thraetening
pulmonary embolism.
 Indication:
 Pulmonary embolism with contraindication to
anticoagulation.
 Recurrent pulmonary embolism despite adequate
anticoagulation.

42.  Pulmonary embolism (PE):
PE is a potentially life-threatening complication associated with DVT.
Sudden shortness of breath, chest pain while inhaling and coughing up
blood may occur with PE.
 Post-phlebitic syndrome:
 which manifest as leg pain and swelling, skin discoloration and skin
sores.
 Treatment complication: Bleeding ( hemorrhages).
 Recurrent DVT
 Chronic venous insufficiency
 Paradoxic emboli

43.  Do regular walking
 Limiting the amount of time you spend sitting
 Exercising daily, mainly walking, swimming or other
activities that promote good blood circulation.
 Avoid wearing tight- fitting clothes for extended periods.
 Drinking lots of fluids

44.  Consuming foods that acts as natural blood thinners to
reduce the risk of developing blood clots, such as
vitamin–E, ginger, cayenne pepper, garlic, turmeric and
cinnamon
 Wearing Elastic compression stockings
 Lower your blood pressure with dietary changes, like
reducing your salt and sugar intake.
 Lose weight if overweight
 Quit smoking

46.  Muscular tear
 Rupture of a Baker’s cyst
 Cellulites or other infection
 Thrombophlebitis
 Tumors
 Connective tissue disorders

48.  Tintinallis emergency medicine
 Rosens emergency medicine
 Dutton. Orthopedic examination, evaluation
and intervention
 Belly and love surery
 Medscape

49. Thank you