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CASE REPORT
1.210 and 30%.79 Until recently, therapeutic antic- have suggested that pre-diagnostic administration
oagulation for DVT was deferred, pending confirma- of therapeutic heparin is safe and may reduce the
tion of the diagnosis by ultrasound scan or risk of pulmonary embolism while awaiting a defi-
venogram. However, the provision of these services nitive diagnosis. However, it has also been reported
outside of normal working hours has placed an that heparinisation increases the risk of acute com-
enormous burden on radiographers, with some cen- partment syndrome secondary to haemorrhage.1,11
tres consequently losing staff.10 This problem has
resulted in the development of pre-emptive hepar- Summary
inisation,2,10 the implementation of which has been
endorsed by the Department of Health.5 Preemptive heparinisation for clinically suspected
Initiating anticoagulation treatment without a DVT is perceived as safe practice with virtually no
definitive diagnosis of DVT is potentially hazardous. complications reported.5 However, this case high-
Gastrocnemius tear or haematoma usually resolves lights the risk of causing acute compartment syn-
spontaneously with no long-term sequelae. In this drome when heparin is given for clinically-suspected
case, the administration of heparin in the presence DVT, when the actual diagnosis is a gastrocnemius
of a gastrocnemius tear appears to have stimulated tear.
further haemorrhage, increasing intra-compart-
mental pressure and precipitating acute compart-
ment syndrome. References
The Department of Health-funded Prodigy web-
site states that in clinically-suspected DVT, diagnos- 1. Allan D, Jones B. Compartment syndrome: a forgotten diag-
tic imaging should be performed within 24 h, if nosis. Lancet 2002;359:2248.
possible. It also states that heparin should be com- 2. Anderson D, Wells P, Stiell I, et al. Thrombosis in the Emer-
gency Department. Use of a clinical diagnosis model to safely
menced (unless strongly contraindicated) until the
avoid the need for urgent radiological investigation. Arch
diagnosis is excluded by such imaging. Differential Intern Med 1999;159:47782.
diagnoses for DVT are listed, which includes muscle 3. Bockenstedt. D-dimer in venous thromboembolism. N Engl J
tear; however, the potential complications of antic- Med 2003;349:12034.
oagulation in this group are not mentioned. 4. Forstner R, Rendl K, Doringer E, Schmoller H. Differential
The Scottish Intercollegiate Guidelines Network diagnosis of the fat lega case report. Vasa 1991;20(5):
4025.
(SIGN)6 guidelines state that if diagnostic imaging is 5. http://www.progidy.nhs.uk/guidanceasp?gt=Deepveinthro-
not immediately available, heparin should be com- mbosis.
menced unless strongly contraindicated and objec- 6. http://www.sign.ac.uk/guidelines/fulltext /36/section2.
tive testing performed as soon as is feasible. The html.
SIGN guidelines also state that a low molecular 7. Huisman MV, Buller HR, Ten Cate JW. Utility of impedance
plethysmography in the diagnosis of recurrent deep vein
weight version of heparin possibly carries a lower thrombosis. Arch Intern Med 1998;148:6814.
risk of haemorrhage compared with other forms of 8. Hull RD, Pineo GF, editors. Disorders of thrombosis. Philadel-
heparin. phia: Saunders; 1996. p. 15974.
Long haul flights may be associated with DVT, but 9. Kennedy D, Setnik G, Li J. Physical findings in deep vein
thrombosis. Emerg Med Clin North Am 2001;19(4):86976.
there are no published data to suggest an increased
10. Langan E, Coffey C, Taylor S, Snyder B, Sullivan T, Cull D, et
DVT risk following short haul flights. al. The impact of the development of a program to reduce
Although the absence of D-dimers, when clinical urgent (off-hours) venous duplex ultrasound scan studies. J
suspicion of DVT is low, has proved useful in reducing Vasc Surg 2002;36:1326.
the number of radiographic investigations,12 a posi- 11. Liu S, Chen W. Medial gastrocnemius hematoma mimicking
tive D-dimer test, is a poor indicator of thrombosis deep vein thrombosis: report of a case. Taiwan Yi Xue Hui Za
Zhi 1989;88(6):6247.
due to its lack of specificity. D-dimers are often 12. Wells PS, Anderson DR, Rodger M, et al. Evaluation of D-dimer
raised in association with inflammation, infection, in the diagnosis of suspected deep vein thrombosis. N Engl J
postoperative haemorrhage and trauma.3 Studies1,4 Med 2003;349:122735.