Case of the Blue Leg: DVT Emergency

[hr]The literal translation is “painful blue edema” and is on a spectrum of infrequent but high-morbidity complications of deep venous thrombosis of the lower extremity.

Phlegmasia alba dolens (painful white edema) occurs when there is severe occlusion of the deep venous drainage, sparing the collateral superficial veins.

It can then progress to phlegmasia cerulea dolens where collateral/superficial venous return is obstructed leading to severe pain, edema, and blue discoloration. The final state is venous gangrene where tissue death occurs.

Edema, violaceous discoloration, and severe pain mark cerulea dolens.

Be aware that patients prone to clots (bedbound, intubated, etc) may not be able to always verbalize pain.

Malignancy, surgery, pregnancy, heparin induced thrombocytopenia, antiphospholipid syndrome, and femoral vein catheterizations are risk factors.

Venous infarction of the limb may occur due to hypoperfusion combined with edema that compresses arterial blood supply. This is a vascular emergency. Compartment syndrome may also develop.

Hypotensive shock secondary to fluid sequestration in the limb.

Pulmonary embolism is a major possible complication of any DVT.

Call vascular surgery immediately as there is the threat of limb loss and even death. Start anticoagulation and elevate the affected limb to increase venous return as much as possible. Start IV fluids if there are signs of intravascular fluid depletion. Surgery may decide to perform catheter directed thrombolysis or venous thrombectomy.