Treat DVT:DOAC first-line — apixaban 10 mg BD ×7 d → 5 mg BD, or rivaroxaban 15 mg BD ×21 d → 20 mg OD (no LMWH bridge). LMWH→warfarin (INR 2–3) if DOAC unsuitable (antiphospholipid syndrome, mechanical valve, severe renal failure CrCl <15–30); 3 mo if provoked, then reassess (ASH 2020; AHA/ACC 2026)
HIT (platelets ↓>50% day 5–10 + thrombosis) →STOP all heparin → Argatroban/fondaparinux; a DOAC (rivaroxaban/apixaban) is an accepted alternative in stable HIT (ASH 2018)
Order set
Duplex ultrasound
D-dimer (if low pretest)
FBC (platelet trend)
Baseline coags
Criteria
AdmitExtensive VTE, PE, or HIT with thrombosis
ICUMassive PE
DischargeAnticoagulated, HIT agent if applicable, duration defined
Never
Order thrombophilia workup for a first clot
Give warfarin alone in acute HIT (→ skin necrosis)
Thrombophilia testing during the acute event or on anticoagulation (unreliable)
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
Signs of PE
Phlegmasia
HIT with thrombosis
Differentials
Cellulitis
Ruptured Baker cyst
Post-thrombotic syndrome
Common mistakes
Thrombophilia testing for first provoked clot
Warfarin alone in acute HIT
Disposition & follow-up
Anticoagulate; HIT → non-heparin agent; provoked VTE 3 months.
Discharge package
MedicationsAnticoagulation (duration per provocation); non-heparin agent in HIT
Follow-upAnticoagulation clinic; review at 3 months
ICU Decoded — original critical-care and internal-medicine pathways by
Dr Javed Akhtar, each cited to a current guideline. For education and quick
reference; verify every dose against local protocols before prescribing.