Signs of DVT can be surprisingly subtle

If a middle-aged woman walked into your ED and told you she felt as if something terrible was going to happen to her, but denied any other symptoms, what would you suspect?

"I took her to one of our critical rooms and while taking her there, she was giving me her daughter's phone number and asking me to call her immediately, because she wanted her there now," recalls Lois Nicholas, RN, an ED nurse at Baylor Medical Center of Irving (TX). "The woman died within an hour of a pulmonary embolism. She had no symptoms except anxiety."

Pulmonary embolism is a potentially life-threatening complication of a deep venous thrombosis (DVT), when a portion of the clot in the peripheral deep vein vessel breaks off and travels into the lungs, says Nicholas. "Ask the patient if they have any shortness of breath or chest pain," she says. "Some patients will verbalize a sense of impending doom or may exhibit a high level of anxiety that is relieved by administration of oxygen."

However, you also need to have a high index of suspicion for the patient who might have a DVT even if they have no clear symptoms. For example, Nicholas says patients might tell you they have "some shortness of breath, vague chest pain, or even a complaint only of anxiety that they cannot explain."

A 32-year-old woman told triage nurses at EMH Regional Medical Center in Elyria, OH, that she was short of breath and that her right calf was swollen for the last three days. "She stated that the pain was worse when she tried to stand on her toe to get a glass out of the cupboard, so she came to the hospital," says Curran Krupar, RN, one of the ED nurses who cared for the patient. "Her only medication was birth control pills."

She was taken to a bed immediately, and a venous duplex was done, along with lab work and a chest CT, looking for a DVT and a pulmonary embolus in her lungs. "Both studies found a clot in her right calf and also in her right lung," says Krupar. "Due to the critical thinking on the nurse's part and asking the right questions, this patient had a high index of suspicion for a DVT and was moved into an ED bed immediately for treatment." The woman was discharged after four days in the hospital and went home on anticoagulation therapy.

Some signs of DVT are very subtle, such as mild pain or swelling, but these can be life-threatening. "Our ED sees a fair share of patient's with DVTs, and patients that are at risk for a DVT," says Krupar.