Dalteparin 2500 units subcut once daily Enoxaparin 40 mg subcut once daily
Neurosurgery, eye surgery, or other surgery when prophylactic anticoagulation is contraindicated
GCS ± IPC
bid, Twice a day; GCS, graduated compression stockings; INR, international normalized ratio; IPC, intermittent pneumatic compression; subcut, subcutaneous; tid, three times a day; UFH, unfractionated heparin; VTE, venous thromboembolism. *Approved only for total hip replacement prophylaxis.
Modified from Goldhaber SZ. Deep vein thrombosis and pulmonary thromboembolism. In Fauci AS, Kasper DL, Braunwald E, et al, eds. Harrison’s Principles of Internal Medicine. 17th ed. New York: McGraw-Hill; 2008:1651-1657; Goldhaber SZ. Pulmonary embolism. In Libby P, Bonow RO, Mann DL, et al, eds. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia: Saunders; 2008:1879.
Treatment requires rapid intervention before vital signs are affected by hypoxia and mechanical failure of the heart. Guidelines for treatment of PE are summarized in the following box.
Guidelines for the Treatment of Pulmonary Embolism
1. Treat DVT or PE with therapeutic levels of unfractionated intravenous heparin, adjusted subcutaneous heparin, or low-molecular-weight heparin for at least 5 days and overlap with oral anticoagulation for at least 4 to 5 days. Consider a longer course of heparin (<10 days) for massive PE or severe iliofemoral DVT.
2. For most patients, heparin and oral anticoagulation can be started together and heparin discontinued on day 5 or 6 if the INR has been therapeutic for 2 consecutive days.
3. Treat patients with reversible or time-limited risk factors for at least 3 months. Patients with a first episode of idiopathic DVT should be treated indefinitely. The approved regimen is warfarin (target INR, 2.0–3.0 for 6 months) followed by low-intensity warfarin (target INR, 1.5–2.0).
4. The use of thrombolytic agents continues to be highly individualized, and clinicians should have some latitude in using these agents. Patients with hemodynamically unstable PE or massive iliofemoral thrombosis are the best candidates.
5. Inferior vena caval filter placement is recommended when there is a contraindication to or failure of anticoagulation, for chronic recurrent embolism with pulmonary hypertension, and with concurrent performance of surgical pulmonary embolectomy or pulmonary endarterectomy.
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