- In addition to PE diagnostic testing, the following lab tests are required for risk stratification and medication selection: complete blood count, basic metabolic panel, and a pregnancy test (for women of childbearing age). Liver function and coagulation tests may also be helpful.
An evidence-based tool to guide the identification and outpatient treatment of patients with low-risk deep vein thrombosis.
- Untreated substance use disorder
- Dysregulated psychiatric disease
- Lack of ability to follow up (e.g. transportation)
- Lack of ability to obtain medications (e.g. no insurance)
- Any other condition that the physician deems as high risk for noncompliance
- DVT in iliofemoral vein
- Concern for phlegmasia cerulea or alba dolens
- Active bleeding
- Previous clinically significant bleeding including: Bleeding in a critical area or organ (e.g. intracranial, intraspinal, intraocular, retroperitoneal, intraarticular, pericardial, intramuscular with compartment syndrome, hemoptysis, airway bleeding), or other bleeding requiring intervention.
- Recent major surgery
- Recent major trauma (including closed head injury without bleeding)
- Recent stroke
- Malignancy in a critical site (e.g. intracranial, spinal, ocular, oropharyngeal, retroperitoneal)
- LMWH: enoxaparin sodium (Lovenox), 1mg/kg SC twice daily or dalteparin sodium (Fragmin), 200 IU/kg SC daily
- Fondaparinux: 5 mg (body weight >50 kg), 7.5 mg (50 to 100 kg), or 10 mg (>100 kg) SC once daily
- If taking medication twice a day and >6 hours until next scheduled dose, take a dose ASAP. If <6 hours until next dose, skip the missed dose and take the next scheduled dose.
- If taking medication once a day and you miss one of the doses, take it asap if >12 hours until the next scheduled dose.
- If <12 hours until next dose, skip the missed dose and take the next scheduled dose.
- If patient takes a double dose, skip next scheduled dose and take the following dose the next day as scheduled.
- If patient misses a dose, skip it and wait until the next schedule dose. Don’t take a double dose to make up for missed dose.
- If patient misses two or more days in a row, contact the anticoagulant clinic or your clinician. The dose may need to be changed.
- If patient a higher dose than prescribed, contact the anticoagulant clinic or your clinician.
- Insurance coverage may need to be confirmed by case management
- A "Med to Bed" or similar programs whereby patients are discharged with their medications in-hand
- The patient's pharmacy may be able to confirm that the anticoagulant is covered by their insurance, without the need for a prior authorization
- A "starter pack" of a DOAC can assist patients in successfully transitioning their dose at week 1 or 3
- Drug manufacturers may offer low-cost, short-term access to medications through their websites for eligible patients
- Consider an observation stay for the first dose of anticoagulant and to provide access to case management and pharmacy resources
Developed by the ACEP Expert Panel on Low-Risk Pulmonary Embolism
and Low-Risk Deep Vein Thrombosis
Reviewed by the ACEP Clinical Resource Review Committee
Christopher Kabrhel MD, MPH, FACEP, FAAEM (chair) Anna Marie Chang, MD Jackeline Hernandez-Nino, MD Alice M. Mitchell, MD, FACEP Rachel Rosovsky, MD, MPH David R. Vinson, MD, FACEP Stephen J. Wolf, MD, FACEP
Jerry Anderson Riane V. Gay, MPA, CAE Liz Muth
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