A 53-year-old woman is brought to the emergency department due to severe headaches, vomiting, and muscle weakness. The patient's medical problems include hypertension and obesity. Her body mass index is 34.2 kg/m². Temperature is 38 C (100.4 F) , blood pressure is 185/105 mm Hg, pulse is 110/min, and respirations are 24/min. Pulse oximetry is 99% on room air. The patient is oriented to person and place only, and has a throbbing headache and paralysis of her left side.
CT head scan without contrast reveals a right hemisphere hemorrhagic stroke.
What is the best next step in preventing deep-vein thrombosis in this patient?

Question

Quizplus · Accepted Answer

Deep-vein thrombosis (DVT) is a significant problem in patients with acute stroke, occurring in up to 15% of patients within the first 30 days, with pulmonary embolism (PE) accounting for up to 25% of all early deaths following stroke. DVTs can develop as soon as 24 hours after the acute event, with peak incidence at days 2-7. Risk factors in stroke patients include hemiparesis (with the risk proportionate to the degree of hemiparesis), atrial fibrillation, immobility, and advanced age. Pharmacologic DVT prophylaxis is recommended for ischemic stroke but is contraindicated for hemorrhagic stroke in the acute setting. Intermittent pneumatic compression (IPC) initiated within 72 hours of an acute stroke prevented DVT in the open-label CLOTS 3 trial. Patients who have been immobilized for more than 72 hours should not be started on IPC without first ruling out DVT due to possible clot dislodgement associated with IPC. (Choices A and E) Graduated compression stockings have not been shown to reduce the risk of proximal lower-extremity DVT after stroke. DVT was more common in stroke patients wearing below-knee-high compared with thigh-high graduated compression stockings in the CLOTS 2 trial. In contrast, thigh-high graduated compression stockings may be harmful (eg, skin breaks, blisters, skin necrosis) in stroke patients, according to the CLOTS 1 trial. (Choice B) D-dimer surveillance is not recommended as primary screening prophylaxis for DVT in patients with acute stroke. (Choice D) Pharmacologic DVT prophylaxis with low-molecular-weight heparin may be considered 1-4 days following hemorrhagic stroke in immobile patients as long as repeat imaging rules out further bleeding. Educational objective: In patients with hemorrhagic stroke, intermittent pneumatic compression started within 72 hours of the acute event is effective in preventing deep-vein thrombosis (DVT). Pharmacologic DVT prophylaxis may be considered 1-4 days following stroke in immobile patients as long as repeat imaging rules out further bleeding. __________ References: Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3): a multicenter, randomised controlled trial. (http://www.ncbi.nlm.nih.gov/pubmed/23727163) Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/22315263) Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial. (http://www.ncbi.nlm.nih.gov/pubmed/19477503) Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. (http://www.ncbi.nlm.nih.gov/pubmed/20651276)

A 53-Year-Old Woman Is Brought to the Emergency Department Due