Question about DVT Diagnosis

EricTAMUCC-BSN, BSN, RN · Dec 11, 2004

Has anyone ever seen a diagnosis of a DVT from just a positive Homan's Sign? If there are no risk factors (no smoking, no BCPs, active person, and younger) do they automatically r/o dx of DVT?
Thanks

No I have not. Generally when a patient is in the hospital for a couple days they order preventative measures like heparin, lovenox, SCDs, and TEDS since they are at risk for coagulopathies due to confinment of the bed or other indicators from the patient's history.

Speaking of DVT prophylaxis what is up with giving heparin or Lovenox SC everyday the patient is in the hospital. The abdomen is tender and most patients dont like to get poked there, lots of times they get jabbed to deep or the heparin causes them to ooze from those spots. Secondly do you really need to be inocculating patients everyday with epidermal floura, and thirdly im tired of getting poked by heparin and lovenox syringes. When I asked a resident why we could not just give coumadin to patients who are awake and can swallow she said that it is a preventitive medication and is not indicated for these situations. I am wondering how it is so different since they both act on the clotting cascade, the only difference is the factors that the medications effect?

SharonH, RN · Dec 12, 2004

Has anyone ever seen a diagnosis of a DVT from just a positive Homan's Sign? If there are no risk factors (no smoking, no BCPs, active person, and younger) do they automatically r/o dx of DVT?
Thanks

No I've only seen a diagnosis of DVT confirmed or ruled out with a Doppler US of lower extremities or a venogram.

actioncat · Dec 12, 2004

You would not give coumadin for DVT prophylaxis-- it is only for those on long term anticoagulation. Its onset of action/duration/half life is much longer than heparin. Generally, they start Coumadin back up when patients are going home.

annmariern · Dec 12, 2004

Lovenox works faster, and has a much shorter half life, I thinks its 12 hrs, where coumadin can take days. Also to get someone theraputic on coumadin takes 3-5 days So until they are theraputic, lovenox is used. Works on different parts of the clotting cascade. Also doesn't need lab monitoring. As for Homans, not too many pts I have had with DVT' s have had a positive sign; mainly its been the swelling of one limb that caused the suspicision of one, Dopplers confirmed. Hard to avoid the bruising of the sites for Lovenox though, especially when the INR is higher. Ouch.

P_RN, ADN, RN · Dec 12, 2004

As far as a Positive Homan's sign there is little correlation with discovery of DVT. It's "acurate" only about 1/2 the time. So you'd get false positives and negatives. Doppler is the way to go for dx. Years ago a venogram would be used....thankfully those are hardley ever done for dx now.

As far as DVT prophylaxis in hospital coumadin (warfarin) is frequently used. Daily INR is required and the goal would be to achieve a stable INR of less than 2.0. The patient may or may not be discharged on coumadin depending on a number of factors.

LMW Heparins such as Lovenox don't require the daily labwork but since they do have the potential for lowering the platelet count, those labs should be done every few days.

curleysue · Dec 12, 2004

I have actually had 3 DVT's. One in my brachial vein in my right arm and two in my right leg. Then I actually developed bilateral PE's a year later. We thing it was due to me being on birth control.

Anyways, I didn't have a positive Homan's Sign. I remember with the DVT's I had severe cramps in the area and throbbing pain shooting up my arm and legs.

When I was put in the hospital I was immediately given Lovenox injections twice a day. Along with coumadin. I only stayed about 3 days for each DVT and each time the treatment was the same. They discharged me when my INR levels were within 2.5-3.5. I am now on coumadin for the rest of my life and I am only 25. It sucks cause I had to have a port-a-cath put in for weekly blood draws and every blood draw my INR is either too high or too low. Diet and the fact I take Ibuprofen for fibromyalgia causes it to change so much. I don't want to do this the rest of my life.

THen when my INR is too low they put me on lovenox shots for a couple days until my INR is up. And I have been hospitalized twice for my INR being up to 27! They thought I would spontaneously bleed somewhere, it was super scary.

Anyways, I just thought I would add in my experience. Take care. Curleysue :uhoh21:

curleysue · Dec 12, 2004

Opps- yes, I meant to say I DID have a positive Homan's Sign. Flexing my foot would increase the pain in my calf tremendously! Curleysue

misswoosie · Sep 25, 2005

Has anyone ever seen a diagnosis of a DVT from just a positive Homan's Sign? If there are no risk factors (no smoking, no BCPs, active person, and younger) do they automatically r/o dx of DVT?
Thanks

Dvt idagnosis isquite complex.We use the Wells score to predict the likelihood of DVT.This includes risk factors and physiological obs of leg.On th basis of this score and the D Dimer ( a lab test to measure breakdown of fibrinogen) result to decide whether to do ultrasound scanning.90% of our DVTs are treated as outpatints.They are assessed in ER and then start LMWH and coumadin ,go home andare then managed by the Clinical Nurse Specialists in ANTICOAG.

Hope this helps

misswoosie · Sep 25, 2005

I have actually had 3 DVT's. One in my brachial vein in my right arm and two in my right leg. Then I actually developed bilateral PE's a year later. We thing it was due to me being on birth control.
Anyways, I didn't have a positive Homan's Sign. I remember with the DVT's I had severe cramps in the area and throbbing pain shooting up my arm and legs.
When I was put in the hospital I was immediately given Lovenox injections twice a day. Along with coumadin. I only stayed about 3 days for each DVT and each time the treatment was the same. They discharged me when my INR levels were within 2.5-3.5. I am now on coumadin for the rest of my life and I am only 25. It sucks cause I had to have a port-a-cath put in for weekly blood draws and every blood draw my INR is either too high or too low. Diet and the fact I take Ibuprofen for fibromyalgia causes it to change so much. I don't want to do this the rest of my life.
THen when my INR is too low they put me on lovenox shots for a couple days until my INR is up. And I have been hospitalized twice for my INR being up to 27! They thought I would spontaneously bleed somewhere, it was super scary.
Anyways, I just thought I would add in my experience. Take care. Curleysue :uhoh21:

Have you seen a haematologist.Wondered if you had had a Thrombophilia screen.You should have been advised not to take Pill after you had your first clot.Brachial clots are quite rare .Also why did you need a portacath-could they not to finger prick tests.Your control sounds really poor.What do you mean about your diet-surely your Vit K intake cant vary that much?

Concerned

UM Review RN, ASN, RN · Sep 25, 2005

Has anyone ever seen a diagnosis of a DVT from just a positive Homan's Sign? If there are no risk factors (no smoking, no BCPs, active person, and younger) do they automatically r/o dx of DVT?
Thanks

OK, you have two questions here. The answer to number one is no. The definitive dx for DVT is made by a venous ultrasound of one or both legs. A positive Homan's might be an indication for a venous ultrasound, however.

No matter if there are risk factors, if your doc thinks you might have a DVT, the ultrasound is ordered to rule out.

Hopefully, the doc will also order a D-dimer, which will trigger for a PE. A D-dimer of >1000 triggers a followup CT angio which rules out or confirms a PE.

Hope that helps.

UM Review RN, ASN, RN · Sep 25, 2005

PS Whoops, once again I've answered a thread that's over a year old. Wonder if the OP is still around??