DVT/PE Flashcards
Typical signs and symptoms of DVT
Unilateral localised pain(usually throbbing in nature) that occurs when walking or bearing weight, and calf swelling
Tenderness
Skin changes, which include oedema, redness and warmth
Vein distension
Tool to assess likelihood of DVT
two-level DVT Wells score
Which patients should be referred for same-day assessment if DVT is suspected
In a woman who is pregnant or has given birth within the past 6 weeks
Next steps of management for patients who are likely to have DVT based on Wells score
Offer a proximal leg vein ultrasound scan with results available within 4 hrs if possible
If proximal leg vein ultrasound cannot be carried out, request for D-dimer test, then
interim therapeutic anticoagulation
Next steps of management for patients who are unlikely to have DVT based on the results of two-level DVT Wells score
Offer a D-dimer test with results available within 4 hrs
Offer interim therapeutic anticoagulation while awaiting the result
Management if D-dimer test is positive
Offer a proximal leg vein ultrasound with the results available within 4 hrs if possible
Interim anticoagulation while waiting
Management if D-dimer test is negative
Stop interim therapeutic anticoagulation
Consider an alternative diagnosis
Tell the person that it is likely they do not have DVT, discuss signs and symptoms of DVT, and when and where to seek further medical help
First line and second line interim therapeutic anticoagulation for suspected DVT
Offer apixaban or rivaroxaban first line
LMWH followed by dabigatran or vitamin K antagonist for at least 5 days if above are not appropriate
Tests which should be carried out for people starting interim anticoagulation therapy
Baseline blood tests including FBC, renal and hepatic function, prothrombin time(PT), and APTT
Maintenance treatment for people with a confirmed DVT
Oral anticoagulant(warfarin, apixaban, dabigatran etc) following acute treatment
How long is maintenance treatment usually continued for DVT
For at least 3 months, but duration may be longer depending on whether DVT was unprovoked or provoked
Usual INR target for patients being treated with warfarin
Target of 2.5, keeping within the range of 2.0-3.0
What should be investigated in patients with unprovoked DVT
Possibility of an undiagnosed cancer if they are not already known to have cancer
Thrombophilia testing as appropriate
When should you suspect a PE
Dyspnoea
Tachypnoea
Pleuritic chest pain
Features of DVT including leg pain and swelling(usually unilateral), lower abdominal pain, redness, increased temperature, and venous distension
Risk factors for PE
DVT Previous VTE Active cancer Recent surgery Significant immobility Lower limb trauma or fracture Pregnancy
Complications of PE
Death
Hypotension(clinically massive PE)
Chronic thromboembolic pulmonary hypertension
Right heart failure
When should you suspect a PE
Dyspnoea Tachypnoea Pleuritic chest pain \+/- Features of DVT including leg pain and swelling(usually unilateral) Lower abdo pain Redness Increased temperature Venous distension
Signs of PE
Tachycardia Hypoxia Pyrexia Elevated JVP Gallop rhythm Pleural rub Hypotension
CXR features that may be present in a PE
Atelectasis
Pleural effusion
Elevation of a hemidiaphragm
ECG signs indicative of a PE
Sinus tachycardia
Non-specific ST-segment and T-wave abnormalities
Right axis deviation
Incomplete or complete right bundle-branch block
T-wave inversion in leads V1-V3
P pulmonale or the classical S1, Q3, T3
When should you arrange immediate admission for people with suspected pulmonary embolism
Signs of haemodynamic instability(pallor, tachycardia, hypotension, shock and collapse)
Pregnant or have given birth within past 6 weeks
Which scoring system can be used to assess likelihood of a PE
Two-level PE Wells score
Management of patients with a Wells score of more than 4 points(PE likely)
Arrange hospital admission for CTPA
Offer interim therapeutic anticoagulation if CTPA cannot be carried out immediately
Management of patients with a Wells score of less than 4 points(PE unlikely)
D-dimer test with interim therapeutic anticoagulation while awaiting the result
If positive, arrange for immediate CTPA
1st line interim therapeutic anticoagulation - PE
Offer apixaban or rivaroxaban
LMWH if not
Appropriate baseline tests for people starting interim anticoagulation therapy
FBC
Renal and hepatic function
Prothrombin time
APTT
Which investigation may be useful in pregnant women with a suspected PE
Lower limb compression venous ultrasound
Pharmacological options for confirmed PE
LMWH
Fondaparinux
Unfractionated heparin
Oral anticoagulant treatment
Mechanical(or physical) interventions in PE management
IVC filters
Thrombolytic therapy
Examples of pharmacological thrombolytics
Streptokinase
Urokinase
rt-PA
VTE risk factors
advancing age obesity family history of VTE pregnancy (especially puerperium) immobility hospitalisation anaesthesia central venous catheter: femoral >> subclavian
Underlying conditions associated with VTE
malignancy thrombophilia: e.g. Activated protein C resistance, protein C and S deficiency heart failure antiphospholipid syndrome Behcet's hyperviscosity syndrome
Medications associated with VTE
COCP
hormone replacement therapy: the risk of VTE is higher in women taking oestrogen + progestogen preparations compared to those taking oestrogen-only preparations
raloxifene and tamoxifen
antipsychotics (especially olanzapine) have recently been shown to be a risk factor
What are thrombophilias
Conditions that predispose patients to blood clots such as:
Antiphospholipid syndrome
Factor V leiden
Antithrombin deficiency
Main contraindication for anti-embolic compression stockings
PAD
Initial anticoagulation choice for DVT/PE
Apixaban
Rivaroxaban
Intervention recommended in patients with a symptomatic iliofemoral DVT
Catheter-directed thrombolysis
How long should anticoagulation be continued for
3 months if there is a reversible cause (then review)
Beyond 3 months if the cause is unclear, there is recurrent VTE, or there is an irreversible underlying cause such as thrombophilia (often 6 months in practice)
3-6 months in active cancer (then review)
What should be investigated in unprovoked DVT
Antiphospholipid syndrome (check antiphospholipid antibodies)
Hereditary thrombophilias (only if they have a first-degree relative also affected by a DVT or PE)
When is thrombolysis recommended in management of PE
Massive PE where there is circulatory failure(hypotension)
Factors considered in two level Wells criteria
Clinical signs and sx of DVT
PE is no.1 diagnosis or equally likely
HR > 100
Immobilisation at least 3 days or surgery in previous 4 weeks
HX of PE/DVT
Haemoptysis
Malignancy
Criteria for PERC rule - to rule out PE
Age > 50 HR > 100 O2 sats < 94% Previous DVT or PE Recent surg/trauma Haemoptysis Unilateral leg swelling Oestrogen use(HRT,contraception)
Interpretation of wells score
PE likely - more than 4 points
PE unlikely - 4 points or less
Definition of provoked PE
an antecedent (within 3 months) and transient risk factor, such as significant immobility, surgery, trauma, pregnancy or puerperium, and the use of the combined contraceptive pill or hormone replacement therapy.
