Snapshot A 45-year-old woman arrives by ambulance to the ED for acute-onset shortness of breath three days after returning from a month-long trip to India. Her O2 saturation is very low and she requires immediate intubation for respiratory support. Introduction Deep venous thrombi (DVT) result from clot-formation in the large veins of the extremities and pelvis Virchow's triad of risk factors for thrombus-formation includes venous stasis resulting from long plane flights, bed rest, or incompetant valves endothelial trauma usually secondary to lower limb injury hypercoagulable state usually in the setting of malignancy, pregnancy, or OCP use Presentation Symptoms patients typically present with unilateral symptoms lower extremity pain erythema swelling in severe cases, patients may also present with shortness of breath indicative of pulmonary embolus secondary to DVT Physical exam Homan's sign calf tenderness with passive dorsiflexion of the foot poor sensitivity and specificity for DVT lower extremity edema respiratory signs indicative of PE Evaluation Doppler ultrasound diagnostic gold standard shows clot formation in the deep venous system Spiral CT or V/Q scan may be used to assess for pulmonary embolism if suspected sometimes part of hospital protocol for DVT/PE screening Differential Arterial insufficiency, venous valvular insufficiency, diabetic vasculitis, edema secondary to CHF or renal insufficiency, trauma Treatment Non-operative initial anticoagulation with IV unfractionated heparin subcutanous LMWH is appropriate in patients with normal renal function, or GFR of at least 30 ml/ min rivaroxaban could be appropriate monotherapy in certain patient populations (stable, non-pregnant, no history of malignancy) long-term anticoagulation PO warfarin for 3-6 months Operative IVC filter placement in patients with contraindications to anticoagulation Prognosis, Prevention, and Complications Prognosis good to excellent in patients adherent to anticoagulation protocols can recur depending on patient-specific comorbidies and risk factors Prevention DVT prophylaxis should be administered to all hospitalized patients and includes exercise/ambulation as tolerated antithromboembolic stockings daily subcutaneous unfractionated heparin or LMWH (for medium and high risk patients only) passengers on long flights are encouraged to stay hydrated by drinking water occasionally stretch legs or walk around the cabin when possible Complications pulmonary embolism (PE) may result from unmanaged DVT caregivers and patients must be aware of the signs and symptoms may be fatal if severe and unrecognized