Emergency Department Venous Thrombo-Embolism Guideline
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Emergency Department Venous Thrombo-
Embolism Guideline
Reference: 1940v1
Written by: Dr L Hickinbotham, D G Hartshorne, Dr J Gilchrist
Peer reviewer: Jeanette Payne
Approved: February 2020
Review Due: October 2022
Purpose
This guideline is designed as a quick reference guide for use in acute presentation
and not to replace the detailed guidelines found linked within this document.
Acute Venous Thrombosis CG1333 4
http://staff.sch.nhs.uk/documents/12-ward-6/148-acute-venous-thrombosis-m3-patients
Intended Audience
This guideline is for use by all clinical staff managing patients presenting acutely with
potential venous thromboembolism
Page 1 of 5CAEC Registration Identifier 1940 Sheffield Children’s NHS Foundation Trust
Venous Thrombo-Embolism Guideline
Contents
A. BACKGROUND
B. ASSESSMENT
C. INVESTIGATIONS
D. MANAGEMENT
A. Background
VTE in children is something that remains a rare presentation (approximately
58 per 10,000 hospital admissions 1) but can have significant consequences
when not identified and treated.
The aim of the guideline is to aid in the assessment and management of
patients presenting with symptoms suggestive of VTE and the subsequent
management.
Differential diagnoses to consider include:
o Pulmonary Embolism
Pneumonia
Sepsis
Congenital heart disease
o Deep vein thrombosis
Vasculitis and thrombophlebitis
Trauma
Cellulitis
B. Assessment
Assessing the patient requires an initial high degree of suspicion and history
taking and examination needs to be focussed once symptoms suggestive of
VTE are recognised.
Symptoms can range from the clinically stable patient with subtle signs to
being overtly unwell and peri-arrest.
Pulmonary Embolism – chest pain, shortness of breath, anxiety, light-
headedness.
Deep vein thrombosis - unilateral limb swelling and pain without history of
trauma.
Examination findings may include:
PE - Apprehension, sweaty/clammy, tachycardia, tachypnoea, hypotension,
hypoxia. If any of the latter signs are present senior involvement and moving
the patient to resus is recommended.
(Haemoptysis is seldom present in children but can be a sign in
adolescents or adults.)
DVT - Leg or arm oedema, erythema, increased warmth, palpable
cord/vessel, tenderness.
Dr L Hickinbotham, D G Hartshorne, Dr J Gilchrist Review date: Oct 2022
© SC(NHS)FT 2020. Not for use outside the Trust. Page 2 of 5CAEC Registration Identifier 1940 Sheffield Children’s NHS Foundation Trust
Venous Thrombo-Embolism Guideline
VTE is thought to be multifactorial in the adolescent population 2 and so
history taking should include looking for risk factors (see table 1) when VTE is
thought to be a possibility.
TABLE 1
RISK FACTORS HYPERCOAGULABLE STATE
Immobilization SLE (Lupus)
Travel (≥ 4 hours in past 1 month) Connective tissue disorders
Surgery (within past 3 months) Nephrotic syndrome
Pregnancy (current or recent) Factor V Leiden Mutation
OCP & Oestrogen replacement (including soon Protein C, S Deficiency
after commencement)
Malignancy Antithrombin Deficiency
Tobacco Use Inflammatory bowel disease
Haemolytic anaemias (Sickle cell) Hyperlipidaemias
Central Venous Instrumentation < 3mo Homocysteinaemia, homocystinuria
Central Venous Catheters
Intravenous Drug Use MEDICATIONS
Stroke, paresis, paralysis Warfarin within days of initiation
Heart failure Phenothiazines
Varicose Veins & Thrombophlebitis
Trauma: Lower Ext, Pelvis < 3 month Family history of VTE in a close relative especially
at a young age
C. Investigations
Laboratory investigation of VTE (such as D-dimer) are not validated in
children as the value may vary with age, therefore making it difficult to
interpret. Further information can be found on the guideline (D-Dimers* in the
Investigation of Venous Thromboembolism) available on the intranet 5.
http://staff.sch.nhs.uk/documents/24-medicine-handbook/1220-d-dimers-in-the-
diagnosis-of-venous-thromboembolism
In a post pubertal child who does not have active malignancy, a central line,
known thrombophilia, strong family history of VTE or nephrotic syndrome with
a pulmonary embolism rule-out criteria (PERC) score of zero then the risk of
PE is very low (CAEC Registration Identifier 1940 Sheffield Children’s NHS Foundation Trust
Venous Thrombo-Embolism Guideline
PERC criteria:
- heart rate >100 beats per minute
- peripheral oxygen saturations 2 hours from presentation to
imaging then the first dose of Low-Molecular Weight Heparin should be
administered prior to referral.
In SC(NHS)FT enoxaparin (Clexane) is used, so to avoid confusion doses are only
quoted for enoxaparin.
Dosing for enoxaparin (Clexane)
Age 2 months
Initial treatment 1.5mg/kg/dose 12hrly sub- 1mg/kg/dose 12hrly sub-
dose cutaneously. cutaneously
Round the dose to the next full 1mg
Full guidance can be found on the guideline: Heparin (CG1020) 6.
http://staff.sch.nhs.uk/documents/12-ward-6/11-heparin-guideline-m3-patients
Dr L Hickinbotham, D G Hartshorne, Dr J Gilchrist Review date: Oct 2022
© SC(NHS)FT 2020. Not for use outside the Trust. Page 4 of 5CAEC Registration Identifier 1940 Sheffield Children’s NHS Foundation Trust
Venous Thrombo-Embolism Guideline
A confirmed VTE requires anti-coagulation initially with LMWH before
commencing vitamin K antagonist (warfarin). Detailed guidance on
commencing warfarin can be found in the guideline: Warfarin and other
outpatient anticoagulation (CG1010) 7. Referral to the on-call medical team
for in-patient management will be necessary.
http://staff.sch.nhs.uk/documents/12-ward-6/5-warfarin-and-other-outpatient-
anticoagulation-for-m3-patients
References
1. Pediatric Thromboembolism. Scott C Howard, MD.
https://emedicine.medscape.com/article/959501-overview#a4 [Accessed 15th
June 2019]
2. Risk factors and co-morbidities in adolescent thromboembolism are different
than those in younger children. Thromb Res. 2016; 141:178-82 (ISSN: 1879-
2472)
3. BNFC [Accessed 2 July 2019]
4. Acute Venous Thrombosis CG1333 http://staff.sch.nhs.uk/documents/12-
ward-6/148-acute-venous-thrombosis-m3-patients [Accessed 19th July 2019]
5. D-dimers in the investigation of Venous Thromboembolism
http://staff.sch.nhs.uk/documents/24-medicine-handbook/1220-d-dimers-in-
the-diagnosis-of-venous-thromboembolism [Accessed 19th July 2019]
6. Heparin (CG1020). http://staff.sch.nhs.uk/documents/12-ward-6/11-heparin-
guideline-m3-patients [Accessed 19th July 2019]
7. Warfarin and other outpatient anticoagulation (CG1010)
http://staff.sch.nhs.uk/documents/12-ward-6/5-warfarin-and-other-outpatient-
anticoagulation-for-m3-patients [Accessed 19th July 2019]
(Section written by Dr L Hickinbotham and D G Hartshorne Dr J Gilchrist, July 2019)
Dr L Hickinbotham, D G Hartshorne, Dr J Gilchrist Review date: Oct 2022
© SC(NHS)FT 2020. Not for use outside the Trust. Page 5 of 5You can also read
