DVT and PE

Question 1

What is DVT?

Answer 1

Deep Vein Thrombosis

Often occurs in the legs

Question 2

What are the risk factors?

Answer 2

Obesity
Immobilisation- long haul flight, post surgery
Age
COCP
Pregnancy
APS
SLE
Previous DVT

Question 3

What are the symptoms of DVT?

Answer 3

Red, hot, swollen, painful leg
Normally unilateral
Distended superficial veins
Can be cyanotic if large vein affected

Question 4

How is DVT diagnosed?

Answer 4

Wells Score

• > 2= DVT likely
• <1=DVT unlikely

Question 5

What investigations are needed if Wells Score predicts DVT is likely?

Answer 5

Proximal leg vein USS within 4hrs
-if positive then commence on treatment

If USS cannot be completed within 4hrs then d-dimer and commence therapeutic treatment
- USS must be done within 24hrs

If d-dimer is positive but USS negative then stop treatment and repeat USS in 6-8 days time

Question 6

What investigations are needed if Wells Score predicts DVT is unlikely?

Answer 6

D-dimer within 4 hours
-if cannot be done within 4hrs then commence on therapeutic anti-coagulation until test done (must be within 24hrs)

If negative- DVT very unlikely

If positive

• Leg vein USS to be completed within 4hrs
• if it cannot be then commence anti-coagulation treatment and ensure it is completed withing 24hrs
• if positive then DVT likely

Question 7

What is the management of DVT?

Answer 7

DOACs (rivoroxaban or apixaban) are treatment of choice for bridging therapy and continuing

In pregnancy- LMWH

In APS- LMWH pre confirmation and warfarin afterwards

If identifiable cause- continue for 3 months
Active cancer- 3-6months
Unknown cause- 6 months

Question 8

What are symptoms of PE?

Answer 8

Dyspnoea
Pleuritic Chest Pain
Haemoptysis

Tachypnoea
Tachycardia

Question 9

How is the likelihood of PE determined?

Answer 9

Wells Score

Suspected DVT= 3 points
Another diagnosis that is not PE is less likely= 3 points
Immobilisation for >3 days or surgery within 4wks= 1.5 points
Previous DVT or PE= 1.5 points
HR >110= 1.5 points
Haemoptysis= 1 point
Malignancy= 1 point

PE likely >4points
PE unlikely =/<4pts

Question 10

What should be done if PE is likely?

Answer 10

CTPA urgently
If cannot be done quickly then therapeutic DOAC to be given

If negative then consider proximal leg USS if concerned of DVT

Question 11

What should be done if PE is unlikely?

Answer 11

D-dimer
If positive then CTPA
If CTPA cannot be done quickly then therapeutic DOAC to be given

If CTPA -ve then stop treatment

Question 12

What is the management of PE?

Answer 12

1) Oral DOACS
- should be given as bridging therapy and continuous therapy unless contraindicated

APS- LMWH followed by warfarin

Pregnancy- LMWH

Continue for at least 3 months

• if provoked course stop after 3
• active cancer 3-6months total
• unprovoked cause- 6 months total

Question 13

What is the Wells Score for predicting likelihood of DVT?

Answer 13

1 point for each of the following

• active cancer
• paralysis/paresis/recent cast immobilisation of limb
• entire leg swollen
• immobilisation >3days or surgery within past 12 weeks
• tenderness along venous aspect of leg
• calf swelling >3cm compared to asymptomatic side
• pitting oedema
• history of previous DVT
• distension of proximal superficial veins

Another diagnosis is at least as likely -2pts

<2pts= DVT unlikely
>2pts=DVT likely