Thoracic Outlet Syndrome in Emergency Medicine Medication

Updated: Aug 25, 2020
  • Author: Andrew K Chang, MD, MS; Chief Editor: Erik D Schraga, MD  more...
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Medication Summary

In patients with evidence of arterial or venous involvement (ischemia or thrombosis), immediate heparinization is indicated in the treatment of thoracic outlet syndrome (TOS).

Anticoagulate with warfarin for a minimum of 3 months for vascular TOS.

Analgesics are seldom helpful except to assist in the institution of a progressive exercise program.

A short-monitored course with tricyclic antidepressants may be helpful if the time course and symptoms suggest a protracted pain syndrome.



Class Summary

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


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.

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.


Tricyclic antidepressants (TCAs)

Class Summary

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.



Class Summary

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.

Acetaminophen and codeine (Tylenol with codeine)

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

Ibuprofen (Motrin, Ibuprin, Nuprin, Advil)

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