DVT & PE Flashcards
What is the first thing you should do if someone has signs/Sx of a DVT?
A 2 level DVT wells score
How to interpret the 2 level DVT well score?
Risk of DVT is likely if pt scores 2 or more points
What should you do if a pt has a 2 level DVT Wells score of over 2 points?
Offer a proximal leg vein USS
What should you do if you have a pt who needs a proximal leg vein USS for a suspected DVT but the results will take >4 hours?
Do a D-diner and offer interim anticoagulation with DOAC and get the USS done within 24 hours
What should you do if a pt has a positive proximal leg vein USS for DVT?
Offer 3-6 months of anticoagulation
What should you do if a pt has a negative proximal leg vein USS for DVT?
Do a D-dimer & stop any interim anticoagulation
If D-dimer is positive then offer a follow up USS in 6-8 weeks
What should you do if a pt has a 2 level DVT Wells score of less than 2 points?
Offer a D-dimer
What should you do if a pt has a wells score <2 and needs a D-dimer but the results can’t be obtained within 4 hours?
Interim anticoagulation whilst awaiting results
What should you do if a pt has a wells score <2 and has a positive D-dimer?
Offer a proximal leg vein USS
(Same rules apply if results wont be available for 4 hours use interim anticoagulation and get USS done in 24 hours)
What should you do if a pt has a wells score <2 and has a negative D-dimer?
Stop any interim anticoagulation
Look for alternative diagnosis as DVT is unlikely
First line anticoagulants for DVT or PE?
A DOAC - specifically apixaban or rivaroxaban
Second line anticoagulants for DVT or PE?
LMWH for 5 days followed by dabigatran or edoxaban
OR
LMWH with a vitamin K antagonist for at least 5 days
First line anticoagulants for DVT or PE with eGFR <15/min?
LMWH OR unfractionated heparin OR LMWH followed by VKA
If starting a pt with suspected DVT or PE on anticoagulants… what blood tests must you do as soon as possible but not necessarily before starting the drug?
FBC
U&E
LFT
PT and APTT
What determines the length of anticoagulation after a DVT or PE?
If it’s provoked its generally 3 months, if pt has cancer 3-6 months and if unprovoked its generally 6 months
However also take into account the ORBIT score to decide on bleeding risk
Outline the ORBIT score?
How do we interpret it?
Age =>75 - 1 point
Hb <130 in men or <120 in women or Hx of anaemia - 2 points
Bleeding history - 2 points
EGFR <60 - 1 point
Tx with antiplatelets - 1 point
0-2 = low bleeding risk
3 = medium bleeding risk
4-7 = high bleeding risk
Possible ECG findings in PE?
Sinus tachycardia is most likely
Right axis deviation
Partial or complete RBBB
Non-specific ST-segment or T-wave abnormalities
T-wave inversion in V1-V3 (p.pulmonale)
S1Q3T3
At is the S1Q3T3 ECG changes that can be seen in 20% of PE cases?
deep S wave in lead I
Q wave in III
inverted T wave in III
What should you do if you think your pre-test probability for a PE is high?
Perform a 2 level PE wells score
How to interpret the 2 level PE wells score?
If >4 points = PE is likely
If <=4 points = PE is unlikely
What should you do next if you have a pt with a high pre-test probability of a PE and had a 2-levels PE wells score of >4 points?
Immediate CTPA
If a PE is likely and you need an immediate CTPA but there will be a delay in the results, what should you do?
Give interim anticoagulants
What should you do if 2 level PE wells score is >4 and your CTPA results are negative?
Consider doing a proximal leg vein USS if a DVT is suspected
What should you do next if you have a pt with a high pre-test probability of a PE and had a 2-levels PE wells score of <=4 points?
Do a D-dimer
What should you do next if you have a pt with a 2-levels PE wells score of <=4 points and your D-dimer is positive?
Immediate CTPA (with interim anticoagulation if delay expected)
What should you do next if you have a pt with a 2-levels PE wells score of <=4 points and your D-dimer is negative?
Consider an alternative diagnosis and stop any interim anticoagulation
How do we diagnose a PE in a pt with an eGFR of <30?
V/Q perfusion scan
What should you do if you think your pre-test probability of a PE is low in.e. <15% chance?
Use the PERC scoring tool and if all aspects are negative the probability of a PE becomes <2%
What tool can be used to determine if a low-risk PE can be treated as an outpatient?
Pulmonary Embolism Severity Index (PESI)
Tx of a PE if the pt is haemodynamically unstable?
Thrombolysis
Tx for pts with repeated PEs despite adequate anticoagulation?
Inferior vena cava filter
Sensitivity and specificity of D-dimer test?
Sensitivity >97%
Specificity <=60%
What can cause a raised D-dimer?
DVT
PE
Pregnancy
Sepsis
Malignancy
Smoking cigarettes
Trauma
Infection
DIC
Systemic illness e.g. MI, AF, unstable angina, pneumonia, vasculitis
