Episode 6 – ACCP Antithrombotics and VTE Guidelines

AT9banner_2012

From American College of Chest Physicians

Antithrombotic Therapy and Prevention of Thrombosis, 9th ed Guidelines

Chest 2012;141:7S-47S (Executive Summary)

For outpatient treatment, start 10 mg daily for the first 2 days followed by INR measurements

Give 1 day of LMWH or UFH before initiation, if treating VTE

If the patient is on VKAs, avoid NSAIDs and certain ABX (table 8 from full guidelines)

Avoid anti-plt agents unless clinical condition warrants

Normal goal is 2-3, including antiphospholipid

No need to taper when d/cing

Heparin – 80/18 for VTE, 70/15 for cardiac or stroke patients

For outpatients with VTE treated with SC UFH, they suggest weight-adjusted dosing (first dose 333 units/kg, then 250 units/kg) without monitoring rather than fixed or weight-adjusted dosing with monitoring

High INRs

4.5-10, no bleeding: no vitamin K necessary

> 10, no bleeding: Oral Vitamin K

If anticoagulant related major bleeding: 4-factor PCC and Vitamin K Slow IV Injection

See Michelle Lin’s Paucis Verbis on the same

Critically Ill Patients

Recommend against routine screening

Use LMWH or LDUH in all patients unless contra-indicated

For travelers at risk of VTE, use graded compression stockings; do not prescribe aspirin or anticoagulants

Diagnosis of DVT

Low Risk

moderate sens d-dimer, high sens d-dimer, or CUS of proximal veins only. D-dimers are preferred

If d-dimer is positive, get Compression Ultrasound (CUS) of proximal veins

Moderate Risk

Use High sens d-dimer, CUS of prox, or CUS of whole leg

Can stop if high-sens D-dimer is negative

If no d-dimer or d-dimer postive, need a second CUS 1 week later if only prox CUS done

If whole leg CUS is negative, you are done

High Risk

Prox CUS or Whole Leg CUS

If prox CUS and d-dimer negative as well, done

If d-dimer positive or only prox CUS, get 1 week f/u CUS

If whole leg CUS is negative, you are done

Recurrent

In patients with past DVT, recommend high-sens d-dimer, if positive get Prox CUS and 1 week Prox CUS

If negative, get just one Prox CUS

If the old CUS is not available, confirm with venography if positive CUS

Upper Ext

Go right to Doppler CUS for upper extremity dvt suspicion

Treatment of DVT

Start with IV or SQ UFH, LMWH, or fondaparinux (Latter two preferred)

If high pretest, start heparin immediately; If moderate, start heparin only if diagnostic tests are expected to be > 4 hours delayed

Isolated distal DVT-serial CUS rather than treatment unless severe symptoms or risk factors for extension (see full text)

Ambulate DVTs, no bed rest

In patients with hypotension (SBP) < 90 and PE, give systemic thrombolytics (through peripheral, rather than PA cath)

Atrial Fib

Chads 0 – nothing

Chads 1/2 – VKA/oral anti-coag; Dabi is preferred

If a-fib > 48 hours; give 3 weeks of VKA/dabi before cardioversion. Or get TEE with LMWH. Follow with 1 month of Vka/oral anti-coag

If a-fib < 48 hours; Start LMWH and then VKA for 4 weeks

If hemodynamically unstable, treat with anticoagulation ASAP preferably before cardioversion and then continue for 4 weeks

Treat a-flutter like a-fib for all of the above

Stroke

If hemorrhagic, can start heparin between days 2-4, LMWH preferred

What is EMCrit Drinking?

A White IPA–Boulevard # 2

 

Play

Follow Practical Evidence to Keep Track of the EBM Goodness

Subscribe to Itunes Subscribe to RSS Subscribe to Email Newsletter

The bandwidth for the Practical Evidence Podcast is provided by EB Medicine. EB Medicine puts out some of the best evidence-based medicine publications for emergency medicine, emergency critical care, and pediatric emergency medicine. Click on the images below for great offers for Practical Evidence listeners.

You finished the 'cast,
Now get CME credit

Not a subcriber yet? Why the heck not?
By subscribing, you can...

  • Get CME hours
  • Support the show
  • Write it off on your taxes or get reimbursed by your department

Sign Up Today!

.

Subscribe Now

If you enjoyed this post, you will almost certainly enjoy our others. Subscribe to our email list to keep informed on all of the ED Critical Care goodness.

This Post was by , published 2 years ago. We never spam; we hate spammers! Spammers probably work for the Joint Commission.

Comments

  1. Merlin Curry says:

    Outstanding podcast! It was less than a week before I heard the first episode that I thought I needed a podcast just like this, knowing it will be immediately practicable. Then I heard the end of the show and it was like a dream! Well done Dr. Weingart, keep up the great works and I’ll be listening.

Speak Your Mind (Along with your name, job, and affiliation)