ORIGINAL ARTICLE

An algorithm for the investigation and management of patients with suspected deep venous thrombosis at a district general hospital

K Walsh, N Kelaher, K Long and P Cervi

Basildon & Thurrock NHS Hospitals Trust, Basildon, Essex

Correspondence to:
Correspondence to:
Dr Kieran Walsh, Basildon Hospital, Nether Mayne, Basildon, Essex SS16 5NL, UK;
kieran{at}kmwalsh.freeserve.co.uk

The aim was to show that clinical assessment and serial Dopplers could be used to exclude deep venous thrombosis (DVT), and also that clinical assessment in combination with D-dimers could be used to exclude DVT. This was a prospective trial. Patients underwent clinical assessment, colour flow Doppler, and D-dimer measurement. Patients with an equivocal first Doppler and patients with a moderate/high pre-test clinical score had a repeat Doppler. Follow up information was obtained to see if further thromboembolism developed. Outcome measures included the reliability of the clinical assessment, Doppler, and D-dimer in excluding DVT. One hundred and ninety four patients were enrolled. The negative predictive value of a low medical pre-test score in excluding DVT was 92%. Eighty eight patients underwent D-dimer measurement. The negative predictive value of a D-dimer <400 units was 96%. The negative predictive value of a low clinical pre-test score and D-dimer <400 units was 100%. The negative predictive value of a low clinical pre-test score and D-dimer <800 units was 97%. The negative predictive value of the combination of a low clinical pre-test score and D-dimer <400 units was 100%. Twenty three per cent of patients had a low clinical pre-test score and D-dimer <400 units. Thus, a DVT could be excluded in 23% of referred patients. This information could be used to reduce Doppler requests by 23%. No patient in whom clinical assessment and serial Dopplers had excluded a DVT suffered further thromboembolism on follow up. This study has thus shown that a low medical pre-test score and negative Doppler reliably exclude DVT; a low pre-test score and negative D-dimer would reliably exclude DVT.

Keywords: deep venous thrombosis; clinical evaluation; colour flow Doppler ultrasonography; D-dimers

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