DVT

Definition

·      Proximal DVT: Clot formation in the popliteal vein or higher.

·      Distal DVT: Isolated clot in the calf veins (anterior/posterior tibial and peroneal veins)

Signs and Symptoms

·      Cramping or calf fullness

·      Lower extremity: unilateral leg swelling, edema, redness (can resemble cellulitis) and pain

·      Upper extremity: arm swelling, finger swelling (ill-fitting rings)

Pre-test Probability

 Wells Score

Dr. Wells – “The model should be applied only after a history and physical suggests that venous thromboembolism is a diagnostic possibility. it should not be applied to all patients with chest pain or dyspnea or to all patients with leg pain or swelling. This is the most common mistake made.”

Ultrasound

·      Diagnostic method of choice

·      Multiple Systems: 3-point system (common, superficial femoral veins, and popliteal veins) and whole leg

·      Low pretest probability

o   A negative 3-point US effectively rules out DVT

o   A negative whole leg US effectively rules out DVT

·      Moderate to High pretest probability

o   Ultrasound does not rule out DVT, must add D-dimer or repeat ultrasound in 1 week.

CT Venogram

·       Can be added on to CTPA that’s being performed for PE.

·       Identifies DVT in the absence of PE in up to 2% of patients

MRI

·       Limited utility due to cost, availability, and no superiority to ultrasound

·       Useful for evaluation of pelvic veins and vena cava

Management 

• Proximal DVT without history of cancer

  • Oral anticoagulant alone (dabigatran, rivaroxaban, apixaban or edoxaban (NOAC)) preferred over a vitamin K antagonist (VKA) (Grade 2B recommendation)

  • VKA preferred to low-molecular weight heparin (LMWH) (Grade 2C recommendation)

  • Duration of treatment: 3 months for 1st clot (Grade 1B recommendation)

• Proximal DVT with cancer

  • LMWH preferred to VKA therapy, dabigatran, rivaroxaban, apixaban or edoxaban (Grade 2C recommendation)

  • Duration of treatment: 3 months for 1st clot (Grade 1B recommendation)

• Distal DVT (isolated)

  • The significance of isolated distal DVTs is unknown.

  • It is unclear whether systemic anticoagulation is beneficial to the patient with these clots

  • Risk factors for extension

    • D-dimer is positive (particularly with larger elevations)

    • Extensive thrombosis (> 5 cm in length, multiple veins, > 7 mm diameter)

    • Proximity to proximal veins

    • No reversible provoking factor for the DVT

    • Active cancer

    • History of VTE

    • Admitted to the hospital

  • Absence of severe symptoms and no risk factors for extension

    • Serial imaging over 2 weeks preferred to anticoagulation (Grade 2C recommendation)

    • No established role for providing antiplatelet therapy (i.e. aspirin) alone in these cases but a reasonable intervention

  • Presence of severe symptoms or risk factors for extension

    • Anticoagulation preferred to serial imaging (Grade 2C recommendation)

    • Anticoagulation choices same as for proximal DVT (Grade 1B recommendation)

• Superficial Thrombophlebitis

  • Saphenous vein clots above the knee can spread into deep venous system via the saphenous-femoral junction

  • Initial treatment with NSAIDs, warm compresses and compression stockings

  • Repeat US in 2-5 days and start anticoagulation if clot extending

• Catheter-Directed Thrombolysis (CDT)

  • Does not show substantial benefits in most patients with proximal DVT and likely increases risk of major bleeding

  • Patients with iliofemoral DVT and a low risk of bleeding may benefit from CDT

Disposition

·       Discharge

Consider if all the following are present:

o   Ambulatory

o   Hemodynamically stable

o   Low risk of bleeding in patient

o   Absence of renal failure

o   Able to administer anticoagulation with appropriate monitoring

o   Able to arrange for 2-3 days follow-up

·       Admit

o   Ileofemoral DVT that is a candidate for thrombectomy (should have the following):

§  Acute iliofemoral DVT (symptom duration <21 days)

§  Low risk of bleeding

§  Good functional status and reasonable life expectancy

o   Phlegmasia Cerulea Dolens

§  DVT that causes phlegmasia cerulea dolens requires rapid action

§  Anticoagulate, place limb at a neutral level, and arrange for consultant-delivered catheter-directed thrombolysis.

§  Transfer if don’t have services or can’t be arranged within 6 hours, consider systemic fibrinolytics if there are no absolute contraindications.

§  One regimen is 50 to 100 milligrams of alteplase infused IV over 4 hours.

o   High risk of bleeding on anticoagulation

o   Significant comorbidities

o   Symptoms of concurrent PE

o   Recent (within 2 weeks) stroke or transient ischemic attack

o   Severe renal dysfunction (GFR < 30)

o   History of heparin sensitivity or HIT

o   Weight > 150kg

o   Upper extremity DVT

References

https://coreem.net/core/deep-venous-thrombosis-dvt/

https://journal.chestnet.org/article/S0012-3692(15)00335-9/fulltext

https://wikem.org/wiki/Deep_venous_thrombosis

Tintanillis Emergency Medicine Comprehensive Study Guide

Maisonneuve Fracture

Trauma:

• Maisonneuve fracture results from an external rotation force applied to the foot

• Force at the medial ankle --> force is directed laterally, tearing the interosseous membrane that tethers the distal tibia to the fibula --> force directed upwards fracturing fibula

Definition:

• Proximal fibula fracture + unstable ankle joint injury

  • Involves a ligamentous injury (distal tibiofibular syndesmosis +/- deep deltoid ligament) and/or fracture of the medial/posterior malleolus.

  • The fibula fracture usually occurs in proximal third but can be as distal as 6 cm above the ankle joint.

• Tibiofibular syndesmosis: fibrous interosseous membrane connecting the tibia/fibula.

  • Disruption leads to joint instability

When to Suspect

• Medial malleolar fracture or deltoid ligament tear without a distal fibular fracture

• Widening of the distal tibiofibular joint without a distal fibular fracture

• Tenderness over the proximal fibula in a patient with an “ankle sprain” or with displaced ankle fractures, including distal fibular fractures

X-Ray Findings

• Abnormal when tibiofibular space >5mm, medial clear space >4mm

• In addition to imaging of the ankle, tib-fib x-rays should also be obtained to evaluate the entire length of tibia/fibula.

• Ankle radiographs can appear “normal” (may only have an occult deep deltoid ligament injury with minimal medial clear space widening

• A stress view of the ankle should be obtained to help identify deep deltoid ligament with associated ankle joint instability.

Management

• Examine all patients with ankle injuries for tenderness along the entire length of the fibula

• Perform Squeeze Test: compression of the tibia/fibula just above the ankle joint. Ankle and/or distal lower leg pain is considered a positive test, suggests syndesmotic injury.

• The common peroneal nerve courses over fibular head. Must perform a thorough neurologic exam.

  • Weakness of ankle dorsiflexion/subtalar joint (foot) eversion and/or numbness along the lateral lower leg/dorsum of the foot should raise clinical suspicion

• Maisonneuve fractures are associated with ankle instability, require surgery.

• If untreated the instability can lead to chronic pain and long-term disability.

• Should reduce and place in a short leg splint, non-weight bearing, immediate orthopedic consult to be seen while in ED.

• Admit patients with open fractures or neurovascular compromise

References

https://coreem.net/core/maisonneuve-fractures/

Tintinalli, 8th edition. Tintinalli’s emergency medicine A comprehensive study guide. McGraw-Hill Education.

https://wikem.org/wiki/Maisonneuve_fracture

Diverticulitis

Diverticulitis used to be thought of as a progressive disease with increasing risk of complications with a greater number of episodes. That general concept drove guidelines for aggressive management, specifically generous antibiotic administration, and surgical interventions. 

More recent data suggests we can be less aggressive with our treatment in the correct patient population.

Epidemiology

·      The incidence of diverticulitis in the United States is 180/100,000 persons per year

·      Diverticulitis is most common in older adults

·      Large increase in cases with younger adults. The incidence of diverticulitis in individuals 40–49 years old increased by 132% from 1980 through 2007 alone

Uncomplicated Diverticulitis vs Complicated Diverticulitis

·      Uncomplicated diverticulitis: thickening of the colon wall and peri-colonic inflammatory changes.

·      Complicated diverticulitis:  abscess, peritonitis, obstruction, stricture, and/or fistula.

·      Small percentage of cases will be complicated

·      Most common complication: abscess or phlegmon

·      Most people recover from, 5% will go on to develop smoldering diverticulitis.

When to Image

·      CT should be performed to confirm diagnosis in previously unimaged patients 

·      Severe presentations

·      Failure of outpatient therapy

·      Immunocompromised

·      Surgical preparation

Immunosuppressed Patients

·      They can present with MILDER symptoms

·      Present with severe or complicated disease

·      Low threshold to image, consult colorectal surgery, and treat with antibiotics

·      Corticosteroid use is a risk factor for diverticulitis and can contribute to complications, including perforation and death.

·      Higher risk to develop complicated diverticulitis from uncomplicated diverticulitis

·      Antibiotics: broad-spectrum agents with gram-negative and anaerobic coverage

·      Longer duration of treatment (10–14 days).

Antibiotics

·      Antibiotic treatment can be used SELECTIVELY, in immunocompetent patients with mild uncomplicated diverticulitis

·      No difference in time to resolution or risk of readmission, progression to a complication, or need for surgery in those treated vs no antibiotics

·      Give antibiotics with uncomplicated diverticulitis who have comorbidities, frail, refractory symptoms, or vomiting

·      Symptoms longer than 5 days

·      CRP >140 mg/L

·      WBC count > 15 x 109 cells/L

Outpatient Antibiotics

·      Regimen includes broad-spectrum agents with gram-negative and anaerobic coverage.

·      Oral fluoroquinolone and metronidazole

·      Or monotherapy with oral amoxicillin/clavulanate.

·      The duration of treatment is usually 4–7 days but can be longer at physicians discretion

Inpatient Antibiotics

·      Ceftriaxone (1 gram IV every 24 hours) + metronidazole (500mg IV every 8 hours)

·      Levofloxacin (500mg IV every 24 hours) + metronidazole (500mg IV every 8 hours)

·      Piperacillin-Tazobactam (3.375 – 4.5g IV every 6 hours)

·      Imipenem-Cilastatin (500mg IV every 6 hours)

Colonoscopy

·      After an episode of complicated diverticulitis and after the first episode of uncomplicated diverticulitis

·      Can defer if within a year colonoscopy was performed

·      Must wait 6–8 weeks or until resolution of symptoms, whichever is longer. Obtain sooner if alarm symptoms

·      Risk of colon cancer complicated diverticulitis (7.9%) vs uncomplicated diverticulitis (1.3%)

When to Admit

·      All complicated diverticulitis

·      Intractable nausea/vomiting

·      Comorbid disease

·      High WBC, fever, elderly, immunocompromised

·      Failed outpatient therapy

·      Large Abscess >3-4cm

When to Discharge

·      Can tolerate PO

·      No significant comorbidities

·      Able to obtain outpatient antibiotics if needed

·      Adequate pain control

·      Uncomplicated disease

·      All newly diagnosed should follow up colonoscopy in 6-8 weeks

·      Surgical referral for all patients with 3rd or 4th episode of diverticulitis

References

https://www.giboardreview.com/wp-content/uploads/2021/12/Guidelines-AGA-diverticulitis-2021.pdf

https://coreem.net/core/diverticular-disease/

http://www.emdocs.net/em3am-diverticulitis/

emDOCs.net – Emergency Medicine EducationEM@3AM - Diverticulitis - emDOCs.net - Emergency Medicine Education

www.emdocs.net

https://wikem.org/wiki/Diverticulitis