You’re on your last patient of the day, starting to thinking about which type of sushi you’re going to order later, when the ultrasound comes back. Positive study, you were sure of it, after all, the patient had a hx of cancer and 3 days of progressive leg swelling and pain. He looked like this:
You start them on lovenox, admit and run off for sushi.
The next day, you get a call from the chairman, he says “remember that patient you admitted….” Oh Oh…
In this case, the patient has something called Phlegmasia Cerulea Dolens. Along with Phlegmasia Alba Dolens, this is caused by clots in the proximal deep veins. It presents with the triad of edema, pain out of proportion and Cyanosis (for Cerulea) or paleness (for Alba).
Cerulea is more severe than Alba. In addition to proximal venous clots, it also involves the collateral veins and can lead to venous gangrene.
Management: In either case, you should call an urgent vascular consult in addition to the standard DVT treatments. Patients with Cerulea will generally go to the OR for thrombectomy or intravenous thrombolytics while patients with Alba usually undergo conservative treatment with close observation, for progression to Cerulea.
Sub-Pearl: Also, Remember the superficial femoral vein is a deep vein. So a clot there IS a DVT.
Further Reading/Listening:
https://www.emrap.org/episode/2014/may/hipporeviews
Mumoli, Nicola, et al. “Phlegmasia cerulea dolens.” Circulation 125.8 (2012): 1056-1057.
Beck, Josh, and Timothy B. Jang. “Short answer question case series: evaluation of the swollen, blue extremity.” Emergency Medicine Journal 29.7 (2012): 604-605.
