DVT & PE

Question 1

What is the first thing you should do if someone has signs/Sx of a DVT?

Answer 1

A 2 level DVT wells score

Question 2

How to interpret the 2 level DVT well score?

Answer 2

Risk of DVT is likely if pt scores 2 or more points

Question 3

What should you do if a pt has a 2 level DVT Wells score of over 2 points?

Answer 3

Offer a proximal leg vein USS

Question 4

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?

Answer 4

Do a D-diner and offer interim anticoagulation with DOAC and get the USS done within 24 hours

Question 5

What should you do if a pt has a positive proximal leg vein USS for DVT?

Answer 5

Offer 3-6 months of anticoagulation

Question 6

What should you do if a pt has a negative proximal leg vein USS for DVT?

Answer 6

Do a D-dimer & stop any interim anticoagulation
If D-dimer is positive then offer a follow up USS in 6-8 weeks

Question 7

What should you do if a pt has a 2 level DVT Wells score of less than 2 points?

Answer 7

Offer a D-dimer

Question 8

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?

Answer 8

Interim anticoagulation whilst awaiting results

Question 9

What should you do if a pt has a wells score <2 and has a positive D-dimer?

Answer 9

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)

Question 10

What should you do if a pt has a wells score <2 and has a negative D-dimer?

Answer 10

Stop any interim anticoagulation
Look for alternative diagnosis as DVT is unlikely

Question 11

First line anticoagulants for DVT or PE?

Answer 11

A DOAC - specifically apixaban or rivaroxaban

Question 12

Second line anticoagulants for DVT or PE?

Answer 12

LMWH for 5 days followed by dabigatran or edoxaban
OR
LMWH with a vitamin K antagonist for at least 5 days

Question 13

First line anticoagulants for DVT or PE with eGFR <15/min?

Answer 13

LMWH OR unfractionated heparin OR LMWH followed by VKA

Question 14

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?

Answer 14

FBC
U&E
LFT
PT and APTT

Question 15

What determines the length of anticoagulation after a DVT or PE?

Answer 15

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

Question 16

Outline the ORBIT score?
How do we interpret it?

Answer 16

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

Question 17

Possible ECG findings in PE?

Answer 17

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

Question 18

At is the S1Q3T3 ECG changes that can be seen in 20% of PE cases?

Answer 18

deep S wave in lead I
Q wave in III
inverted T wave in III

Question 19

What should you do if you think your pre-test probability for a PE is high?

Answer 19

Perform a 2 level PE wells score

Question 20

How to interpret the 2 level PE wells score?

Answer 20

If >4 points = PE is likely
If <=4 points = PE is unlikely

Question 21

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?

Answer 21

Immediate CTPA

Question 22

If a PE is likely and you need an immediate CTPA but there will be a delay in the results, what should you do?

Answer 22

Give interim anticoagulants

Question 23

What should you do if 2 level PE wells score is >4 and your CTPA results are negative?

Answer 23

Consider doing a proximal leg vein USS if a DVT is suspected

Question 24

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?

Answer 24

Do a D-dimer

Question 25

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?

Answer 25

Immediate CTPA (with interim anticoagulation if delay expected)

Question 26

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?

Answer 26

Consider an alternative diagnosis and stop any interim anticoagulation

Question 27

How do we diagnose a PE in a pt with an eGFR of <30?

Answer 27

V/Q perfusion scan

Question 28

What should you do if you think your pre-test probability of a PE is low in.e. <15% chance?

Answer 28

Use the PERC scoring tool and if all aspects are negative the probability of a PE becomes <2%

Question 29

What tool can be used to determine if a low-risk PE can be treated as an outpatient?

Answer 29

Pulmonary Embolism Severity Index (PESI)

Question 30

Tx of a PE if the pt is haemodynamically unstable?

Answer 30

Thrombolysis

Question 31

Tx for pts with repeated PEs despite adequate anticoagulation?

Answer 31

Inferior vena cava filter

Question 32

Sensitivity and specificity of D-dimer test?

Answer 32

Sensitivity >97%
Specificity <=60%

Question 33

What can cause a raised D-dimer?

Answer 33

DVT
PE
Pregnancy
Sepsis
Malignancy
Smoking cigarettes
Trauma
Infection
DIC
Systemic illness e.g. MI, AF, unstable angina, pneumonia, vasculitis