Venous Thromboembolism Observation Unit

Aka: Venous Thromboembolism Observation Unit, VTE Emergency Department Observation Unit, Venous Thromboembolism EDOU, Deep Vein Thrombosis Observation Unit, DVT Emergency Department Observation Unit, Deep Vein Thrombosis EDOU, Pulmonary Embolism Observation Unit, PE Emergency Department Observation Unit, Pulmonary Embolism EDOU

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II. Indications

  1. Acute Venous Thromboembolism AND
  2. Hemodynamic stability with low clot burden AND
  3. Requires additional assistance while initiating outpatient management (via case management and social services)
    1. Outpatient Anticoagulation initiation
    2. Establish outpatient follow-up care at week 1 and week 4

III. Contraindications

  1. Contraindications to Anticoagulation
    1. High bleeding risk on Anticoagulation
    2. Gastrointestinal Bleeding
    3. Surgery in prior 2 weeks
    4. Cerebrovascular Accident in last month
    5. Bleeding Disorder
    6. Platelet Count <75,000
    7. Uncontrolled Hypertension (>180/110)
  2. DVT with Acute Limb Ischemia or high clot burden NOT amenable to Intervention Radiology thrombectomy
  3. High risk Pulmonary Embolism
    1. Right heart strain (on echo or CT chest)
    2. Elevated cardiac biomarkers (e.g. serum Troponin, BNP)
    3. Large central Pulmonary Embolism (e.g. Saddle PE)
    4. Hypoxia on room air (Oxygen Saturation <90%)
    5. Hemodynamic instability
      1. Hypotension or Cardiogenic Shock (esp. requiring Vasopressor therapy)
      2. Syncope
      3. Sinus Tachycardia (Heart Rate >110 bpm)
  4. High risk social situations in which disposition is not possible within 24-48 hours
    1. Uncontrolled mental illness or Substance Abuse
    2. Homelessness
    3. Decreased medical decision making without a reliable surrogate decision maker
  5. Low risk DVT or PE (discharge home on Anticoagulation is preferred over hospital stay)
    1. Most DVT patients (non-proximal, non-high clot burden) may be discharged home on Anticoagulation
      1. See Deep Vein Thrombosis
    2. Stable, segmental or subsegmental PE patients without significant comorbidity may be discharged home
      1. See Pulmonary Embolism Management
      2. See Pulmonary Embolism Severity Index (PESI)
      3. See Simplified PESI

IV. Management

  1. Acute iliofemoral DVT (iliac vein or common femoral vein) for <14 days
    1. Increased risk for Post-Thrombotic Syndrome and recurrent VTE
    2. Consult Intervention Radiology for possible thrombectomy or directed Thrombolysis
  2. Anticoagulation
    1. Initiate DOAC
  3. Monitoring
    1. Telemetry
    2. Continuous Pulse Oximetry
  4. Additional testing to consider
    1. Bilateral lower extremity venous Doppler Ultrasound
    2. Echocardiogram
  5. Disposition Discharge Criterua
    1. Hemodynamic stability (systolic Blood Pressure 90 to 180 mmHg, Heart Rate <100 bpm)
    2. Oxygen Saturation >90%
    3. Patient ambulatory and at baseline functional status

V. References

  1. Busman and Pasternak (2025) Crit Dec Emerg Med 39(7): 4-13
  2. Gaddy (2017) Emerg Med Clin North Am 35(3):549-69 +PMID: 28711124 [PubMed]

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