eMedicine Specialties > Emergency Medicine > Cardiovascular

Thoracic Outlet Syndrome: Treatment & Medication

Author: Andrew K Chang, MD, Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center
Coauthor(s): J Stephen Bohan, MD, FACP, FACEP, Director, Observation Medicine, Department of Emergency Medicine, Clinical Director, Harvard Medical School, Brigham and Women's Hospital
Contributor Information and Disclosures

Updated: Jan 25, 2010

Treatment

Emergency Department Care

Most presentations of thoracic outlet syndrome (TOS) to the ED are nonemergent and require only symptomatic treatment and referral. Vascular thoracic outlet syndrome, although much less common than neurologic thoracic outlet syndrome, requires more urgent care.

  • Vascular (arterial and venous)
    • Immediate heparinization
    • Vascular surgery consultation
    • Color flow duplex scanning
    • Angiography or venography
  • Neurologic - Conservative outpatient physiotherapy

Consultations

  • Neurologic, orthopedic, or vascular surgery consultation(s) may be indicated depending on the type of pathologic condition.
  • Physical medicine and rehabilitation physicians are needed for outpatient workup.

Medication

In patients with evidence of arterial or venous involvement (ischemia or thrombosis), immediate heparinization is indicated.

Anticoagulants

These agents prevent recurrent or ongoing thromboembolic occlusion of the vertebrobasilar circulation.


Heparin

Augments activity of antithrombin III and prevents conversion of fibrinogen to fibrin. Does not actively lyse but is able to inhibit further thrombogenesis. Prevents re-accumulation of clot after spontaneous fibrinolysis.

Adult

Loading dose: 80 U/kg
Maintenance infusion: 18 U/kg/h
Alternatively, start with 50 U/kg/h, followed by continuous infusion of 15-25 U/kg/h; increase by 5 U/kg/h q4h prn using aPTT results

Pediatric

Loading dose: 50 U/kg/h
Maintenance infusion: 15-25 U/kg/h
Increase dose by 2-4 U/kg/h q6-8h prn using aPTT results

Digoxin, nicotine, tetracycline, and antihistamines may decrease effects; NSAIDs, aspirin, dextran, dipyridamole, and hydroxychloroquine may increase toxicity

Documented hypersensitivity; subacute bacterial endocarditis; active bleeding; history of heparin-induced thrombocytopenia

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

In neonates, preservative-free heparin is recommended to avoid possible toxicity (ie, gasping syndrome) by benzyl alcohol, which is used as preservative; caution in severe hypotension and shock


Warfarin (Coumadin)

Interferes with hepatic synthesis of vitamin K–dependent coagulation factors. Used for prophylaxis and treatment of venous thrombosis, pulmonary embolism, and thromboembolic disorders. Tailor dose to maintain INR in range of 2-3. Infants may require doses at, or near, high end of range.

Adult

5-15 mg/d PO qd for 2-5 d; adjust dose according to desired INR

Pediatric

0.05-0.34 mg/kg/d PO; adjust dose according to desired INR

Drugs that may decrease anticoagulant effects include griseofulvin, carbamazepine, glutethimide, estrogens, nafcillin, phenytoin, rifampin, barbiturates, cholestyramine, colestipol, vitamin K, spironolactone, oral contraceptives, and sucralfate
Medications that may increase anticoagulant effects include oral antibiotics, phenylbutazone, salicylates, sulfonamides, chloral hydrate, clofibrate, diazoxide, anabolic steroids, ketoconazole, ethacrynic acid, miconazole, nalidixic acid, sulfonylureas, allopurinol, chloramphenicol, cimetidine, disulfiram, metronidazole, phenylbutazone, phenytoin, propoxyphene, sulfonamides, gemfibrozil, acetaminophen, and sulindac

Documented hypersensitivity; severe liver or kidney disease; open wounds; GI ulcers

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Do not switch brands after achieving therapeutic response; caution in active tuberculosis or diabetes; patients with protein C or S deficiency are at risk of developing skin necrosis

Tricyclic antidepressants (TCAs)

If analgesic treatment is ineffective, a short, monitored course of TCAs can be helpful if the time course and symptoms suggest a protracted pain syndrome. The primary care physician or neurologist (not the ED physician) should be the one to prescribe such therapy.


Doxepin (Sinequan, Adapin, Zonalon)

Inhibits histamine and acetylcholine activity and has proven useful in treatment of various forms of depression associated with chronic and neuropathic pain.

Adult

30-150 mg/d PO hs or in 2-3 divided doses; gradually increase dose to 300 mg/d prn

Pediatric

<12 years: Not recommended
>12 years: 25-50 mg/d PO hs or bid/tid and increase gradually to 100 mg/d

Decreases antihypertensive effects of clonidine but increases effects of sympathomimetics and benzodiazepines; effects increase with phenytoin, carbamazepine, and barbiturates

Documented hypersensitivity; urinary retention; acute recovery phase following myocardial infarction; glaucoma

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in cardiovascular disease, conduction disturbances, seizure disorders, urinary retention, and hyperthyroidism and in patients receiving thyroid replacement; perform baseline and periodic leukocyte and differential counts and liver function tests; discontinue if evidence of neutropenia

Analgesics

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and enables physical therapy regimens. Many analgesics have sedating properties, which are beneficial for patients who have sustained injuries.


Acetaminophen (Tylenol, Aspirin Free Anacin, Feverall)

DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.

Adult

325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d

Pediatric

<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h

Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity

Documented hypersensitivity; known G-6-PD deficiency

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate serious illness; acetaminophen contained in many OTC products, and combined use with these products may result in cumulative acetaminophen doses exceeding recommended maximum dose


Acetaminophen and codeine (Tylenol with codeine)

Drug combination indicated for treatment of mild to moderately severe pain.

Adult

30-60 mg/dose based on codeine content PO q4-6h or 1-2 tab q4h; not to exceed 12 tabs in 24h

Pediatric

0.5-1 mg/kg/dose based on codeine PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen

CNS depressants or tricyclic antidepressants increase toxicity

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients dependent on opiates, since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction


Ibuprofen (Motrin, Ibuprin, Nuprin, Advil)

DOC for patients with mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Adult

200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d

Pediatric

<6 months: Not established
6 months to 12 years: 30-70 mg/kg/d divided PO tid/qid; not to exceed 2.4 g/d
>12 years: Administer as in adults

Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants—monitor PT closely and instruct patients to watch for signs of bleeding; may increase risk of methotrexate toxicity; may increase phenytoin levels

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy

More on Thoracic Outlet Syndrome

Overview: Thoracic Outlet Syndrome
Differential Diagnoses & Workup: Thoracic Outlet Syndrome
Treatment & Medication: Thoracic Outlet Syndrome
Follow-up: Thoracic Outlet Syndrome
References
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References

  1. Fugate MW, Rotellini-Coltvet L, Freischlag JA. Current management of thoracic outlet syndrome. Curr Treat Options Cardiovasc Med. Apr 2009;11(2):176-83. [Medline].

  2. Sanders RJ, Hammond SL, Rao NM. Diagnosis of thoracic outlet syndrome. J Vasc Surg. Sep 2007;46(3):601-4. [Medline].

  3. Demondion X, Herbinet P, Van Sint Jan S, Boutry N, Chantelot C, Cotten A. Imaging assessment of thoracic outlet syndrome. Radiographics. Nov-Dec 2006;26(6):1735-50. [Medline].

  4. Huang JH, Zager EL. Thoracic outlet syndrome. Neurosurgery. Oct 2004;55(4):897-902; discussion 902-3. [Medline].

  5. Barkhordarian S. First rib resection in thoracic outlet syndrome. J Hand Surg [Am]. Apr 2007;32(4):565-70. [Medline].

  6. Franklin GM, Fulton-Kehoe D, Bradley C, Smith-Weller T. Outcome of surgery for thoracic outlet syndrome in Washington state workers' compensation. Neurology. Mar 28 2000;54(6):1252-7. [Medline].

  7. Aufderheide TP. Peripheral arteriovascular disease. Emerg Med: Concepts and Clinical Practice. 1998;2:1844-7.

  8. Hood DB, Kuehne J, Yellin AE, Weaver FA. Vascular complications of thoracic outlet syndrome. Am Surg. Oct 1997;63(10):913-7. [Medline].

  9. Oates SD, Daley RA. Thoracic outlet syndrome. Hand Clin. Nov 1996;12(4):705-18. [Medline].

  10. Plewa MC, Delinger M. The false-positive rate of thoracic outlet syndrome shoulder maneuvers in healthy subjects. Acad Emerg Med. Apr 1998;5(4):337-42. [Medline].

  11. Sanders RJ, Hammond SL, Rao NM. Thoracic outlet syndrome: a review. Neurologist. Nov 2008;14(6):365-73. [Medline].

  12. Weber RJ, Lebduskin S. Rehabilitation issues in plexopathies. Phys Med Rehabil. 1988;996-8.

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Further Reading

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Keywords

thoracic outlet syndrome, nerve compression syndrome, thoracic outlet syndrome causes, thoracic outlet syndrome symptoms, TOS, vascular thoracic outlet syndrome, neurologic thoracic outlet syndrome, arterial thoracic outlet syndrome, venous thoracic outlet syndrome, compression of neurovascular structures, neurovascular entrapment

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Contributor Information and Disclosures

Author

Andrew K Chang, MD, Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center
Andrew K Chang, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

J Stephen Bohan, MD, FACP, FACEP, Director, Observation Medicine, Department of Emergency Medicine, Clinical Director, Harvard Medical School, Brigham and Women's Hospital
J Stephen Bohan, MD, FACP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians, and Royal Society of Medicine
Disclosure: Nothing to disclose.

Medical Editor

Richard S Krause, MD, Senior Faculty, Department of Emergency Medicine, State University of New York at Buffalo School of Medicine
Richard S Krause, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

David Eitel, MD, MBA, Associate Professor, Department of Emergency Medicine, York Hospital
David Eitel, MD, MBA is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

David FM Brown, MD, Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital
David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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