Occupational Therapy DVT & PE Evidence-Based Screening (2019)

This post focuses on current evidence-based screening techniques for OTs who have a suspicion of DVT or PE for their patients, which will allow OTs to take appropriate action because of the risk of complications or death (due to PE). These techniques do not rule out a DVT or PE.

  • 50% of cases with confirmed DVT had a normal physical examination.
  • 75% of suspected cases are found not to have DVT with formal diagnostic testing.

Background

  • Venous thromboembolism (VTE) includes DVTs (deep vein thrombosis) and PEs (pulmonary embolism).
  • Proximal DVTs (PDVT) involve popliteal, femoral, external iliac, and deep vein of the thigh.
    • Proximal deep vein thrombosis (PDVT) is the more dangerous form of lower extremity DVT because it is more likely to cause life-threatening PE.
  • Distal DVTs develop in the calf.
  • DVTs in the upper extremity are less common.
  • Proximal upper extremity DVTs involve the jugular, brachiocephalic, subclavian, and axillary veins.
  • Distal upper extremity DVTs involve the brachial, ulnar, and radial veins.

Risks

  • Orthopedic procedures may carry a high risk for VTE (destruction of bone marrow, cell fragments, elevated plasma tissue factor – trigger of blood clotting)
  • Neurosurgery incidence reported being as high as 50%.
    • Intracranial surgery, malignant tumors, increased duration of surgery, paresis of lower extremities.

woman holding her chest due to pain

PE Clinical Manifestations

  • Dyspnea
  • Angina
  • Syncope

Survey

What techniques do you use to evaluate a patient for DVT?

dvt screening survey response graph

    • Homan’s sign (long taught as a useful clinical sign) is of no value in the diagnosis of DVT and should be omitted from the examination.
      • Evidence of Homan’s sign being unreliable, insensitive, and nonspecific for DVT diagnosis, with it being sensitive about 50% of the time.
    • Groups of signs and symptoms are more useful.
    • Wells and colleagues developed a clinical rule that combines the results of 9 carefully defined signs and symptoms to screen for DVTs.

Updated Well’s Criteria (2 possible result categories)

DVT likely – 2 points or more

  • Paralysis, paresis, or recent plaster immobilization of LEs (1pt)
  • Recent bedrest 3 days or more, or major surgery within 12 weeks requiring general or regional anesthesia (1pt)
  • Localized tenderness along the deep venous distribution (1pt)
  • Entire leg is swollen (1pt)
  • Calf edema at least 3 cm larger than asymptomatic side (1pt)
  • Pitting edema confined to the symptomatic side (1pt)
  • Collateral superficial veins (non-varicose) (1pt)
  • Previously documented DVT (1pt)
  • Alternative diagnosis at least as likely as DVT (-2pts)

Padua Prediction Score for Risk of VTE

High risk of VTE = Greater than or equal to 4

  • Active cancer +3
  • Previous VTE +3
  • Reduced mobility +3
  • Known thrombophilic condition +3
  • Recent trauma or surgery (less than or equal to 1 month) +2
  • Elderly age (greater than or equal 70 years) +1
  • Heart and/or respiratory failure +1
  • Acute MI and/or ischemic stroke +1
  • Acute infection and/or rheumatologic disorder +1
  • Obesity (BMI greater than or equal 30) +1
  • Ongoing hormonal treatment +1

DVT Differential Diagnosis

  • Muscle hematoma
  • Muscle or tendon tear
  • Muscle cramp
  • Superficial thrombophlebitis
  • Postphlebitic syndrome
  • Cellulitis
  • Sciatica
  • External venous compression

Occupational Therapy Prevention of DVT and PE

  • Early mobilization and physical activity
  • Leg exercises
  • Hydration
  • Education of VTE/DVT/PE

Sources:

https://www.physio-pedia.com/Deep_Vein_Thrombosis

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