DVT and Pulmonary Thromboembolism

Question 1

What is a thromboembolism.

Answer 1

Thromboembolism”

Movement of blood clot along a vessel

Question 2

Examples of VTE

Answer 2

Limb deep vein thrombosis (DVT)
Pulmonary embolism (PE)

Visceral venous thrombosis
Intracranial venous thrombosis

Question 3

Risk factors for VTE

Answer 3

Question 4

Describe prevention of VTE in hospital.

Answer 4

Early mobilisation
‘Anti-embolism stockings’
Other mechanical methods of thromboprophylaxis
Pharmacological thromboprophylaxis

Question 5

Describe the presentation of DVT

Answer 5

Symptoms and signs of DVT

Unilateral limb swelling
Persisting discomfort
Calf tenderness

[Warmth]
[Redness- erythema]
[Prominent collateral veins]
[Unilateral pitting oedema]

May be clinically silent

Question 6

Describe the presentation of Pulmonary thromboembolism

Answer 6

Pleuritic chest pain
Breathlessness- dyspnoea
[Blood in sputum- haemoptysis]
Rapid heart rate- tachycardia
Pleural rub on auscultation
usually due to pulmonary infarction

Question 7

Describe the investigation of DVT

Answer 7

Clinical assessment and pretest probability score (Wells score)

Blood test: D-dimer if low pre-test probability score

Imaging: Compression ultrasound if positive D-dimer or high pre-test probability score

Question 8

Describe the investigation/diagnosis of Pulmonary thromboembolism

Answer 8

Clinical assessment and pretest probability score (Wells score or Geneva score)
Blood test: D-dimer if low pre test probability score
Imaging: if D-dimer positive or high pre test probability score
Isotope ventilation/perfusion scan
CT pulmonary angiogram

Question 9

Symptoms and signs of massive pulmonary embolism

Answer 9

Severe dyspnoea of sudden onset
Collapse
Blue lips and tongue - cyanosis
Tachycardia
Low blood pressure
Raised jugular venous pressure
May cause sudden death

Question 10

Describe Well’s score for DVT

Answer 10

Question 11

Describe the diagnostic algorithm for DVT.

Answer 11

Question 12

What is a D-dimer?

Answer 12

Breakdown product of cross-linked fibrin
Produced during fibrinolysis

High sensitivity for VTE

Low specificity for VTE
Trauma, malignancy, sepsis, bleeding, cancer, recent surgery

Question 13

Describe wells score for PE

Answer 13

Question 14

If DVT and PE both fall under the category of venous thromboembolism, describe the treatment for this.

Answer 14

Treatment options:
Anticoagulation is main treatment
Provoked – 3/12
Unprovoked and high risk of recurrence- Lifelong

Vascular surgical interventions in massive DVTs
Thrombolysis reserved for massive PE (Collapse, haemodynamic compromise ie. Shocked Patient)
E.g. Alteplase

Question 15

Aims of treatment of VTE.

Answer 15

Prevent clot extension
Prevent clot embolisation
Prevent recurrent clot

Question 16

Potential long-term consequence of DVT.

Answer 16

Post Thrombotic Syndrome
Damage to venous valves
Incidence of 20-60% within 2 years of DVT

Swelling
Discomfort
Pigmentation
Ulceration in severe form

Question 17

Potential long-term consequences of pulmonary embolism.

Answer 17

Most recover fully
Pulmonary arterial hypertension
Serious outcome
4% patients (< 1/20)