DVT and PE

Question 1

What is the mechanism of venous problems?

Answer 1

Virchow’s Triad.
Stasis - immobility.
Hypercoagulability - pregnancy, cancer, sepsis.
Vessel damage - hypertension, smoking, high cholesterol, venous catheters, trauma, surgery.

Question 2

What are the risk factors and management of VTE?

Answer 2

Includes DVT and PE.
Risk factors - age, surgery, late pregnancy, reduced mobility, CHD, congestive cardiac failure, hypertension, COPD, obesity.
Management - early mobilisation, compression stockings, drugs.

Question 3

What are the signs and symptoms of DVT?

Answer 3

Signs - unilateral pitting oedema, prominent collateral veins, erythema.
Symptoms - warmth, unilateral limb swelling, persisting discomfort, calf tenderness, may be clinically silent.

Question 4

What is the diagnosis of DVT?

Answer 4

Clinical assessment.
Wells score - considers cancer, mobility, swelling, dilated superficial veins, previous DVT, and alternative diagnoses.
D-dimer (if low Wells Score) - high sensitivity and low specificity for VTE.
Compression US (if positive D-dimer or a high Wells Score).

Question 5

What is the diagnostic management of patients with suspected DVT?

Answer 5

Likely clinical probability - US.
Normal - D-dimer. Repeat US is positive. Stop if negative.
Abnormal - treat.

Unlikely clinical probability - D-dimer.
Positive - US. Stop if normal. Treat if abnormal.
Negative - stop.

Question 6

What are the treatment and long-term consequences of DVT?

Answer 6

Massive - vascular surgical interventions.
Aim to prevent clot extension, embolisation, and recurrence.
Long-term consequences - post-thrombotic syndrome (damage to venous valves, incidence of ~40% within 2yrs of DVT). Swelling, discomfort, pigmentation, severe ulceration.

Question 7

What are the signs and symptoms of PE?

Answer 7

Signs - pleural rub on auscultation (pulmonary infarction), tachycardia, pleuritic chest pain.
Symptoms - SOB and haemoptysis.

Question 8

What are the signs and symptoms of a massive PE?

Answer 8

Signs - low BP and a raised JVP.
Symptoms - severe SOB, collapse, cyanosis, sudden death.

Question 9

What is the diagnosis of PE?

Answer 9

Wells Score.
Clinical assessment
D-dimer (if low Wells Score).
V/Q scan or CT pulmonary angio (if D-dimer is positive or high Wells Score).

Question 10

What is the treatment for PE?

Answer 10

Anticoagulation (if provoked, 3 months; if unprovoked and a high recurrence risk, lifelong).
S/C Dalteparin (first line for pregnant patients).
Rivaroxaban (no monitoring, given to most).
Warfarin or heparin (close monitoring)
Thrombolysis (massive PE).