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A 79-year-old man is admitted to the medical ward 3 days status post subdural hematoma drainage, C3 cervical spine fracture, and fixation of multiple extremity fractures sustained in a motor vehicle accident. The patient is now awake and oriented to person, place, and time, but is a lower cervical spine incomplete quadriplegic. Physical examination reveals some minimal sensation in the legs, but no ability to move the extremities. There is a Foley catheter in place that is draining yellow colored urine. Doppler ultrasonography demonstrates a thrombus in the left popliteal vein. The most important next step in the management of this patient is
A. daily Doppler ultrasonography of the lower extremities
B. inferior vena cava filter placement
C. subcutaneous heparin
D. tissue plasminogen activator thrombolysis
E. warfarin
F. weekly ventilation/perfusion scans for a pulmonary embolus
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b - inferior vena cava filter placement ..as there is CI to use of anticoagulants
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B. inferior vena cava filter placement
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perfect
The correct answer is B. This patient has documented deep venous thrombosis (DVT) on ultrasonography and has had recent intracranial surgery. Intracranial surgery is an absolute contraindication to anticoagulation. Because the patient has a documented DVT, an inferior vena cava filter is necessary to prevent potentially fatal pulmonary emboli.
Daily ultrasonography of the lower extremities (choice A) is a way to follow the extent of the documented thrombus in the left popliteal vein. It is not sufficient to simply follow the extent of the clot, however. The known DVT puts him at a risk for a pulmonary embolus, and therefore he needs an inferior vena cava filter.
Anticoagulation with subcutaneous heparin (choice C) is absolutely contraindicated as the patient has had recent neurosurgery.
Thrombolysis (choice D) will treat the current thrombus in the left popliteal vein, but it will not prevent further thromboses from occurring. Thrombolysis with tissue plasminogen activator is also contraindicated so soon after intracranial surgery.
Anticoagulation with warfarin (choice E) is absolutely contraindicated as the patient has had recent neurosurgery.
A screening study for pulmonary emboli (choice F) is inadequate for this high-risk patient. Although both ventilation/perfusion scanning and CT pulmonary angiography are effective studies to diagnosis a pulmonary embolus, this patient needs definitive treatment to prevent a pulmonary embolus.
