pulmonary embolism, venous thromboembolism, PE / VTE

Question 1

VTE - proximal DVT or PE - Rx

Answer 1

apixaban 10mg bd for 7 days then 5mg bd 
OR
rivaroxaban 15mg bd for 21days then 20mg od 
OR
warfarin target INR 2-3
AND
enoxaparin 1.5mg/kg subcut for 5 days

Question 2

Proximal DVT - location

Answer 2

iliac and femoro-popliteal -
deep femoral, common femoral
iliac
popliteal veins

Question 3

Distal DVT - location

Answer 3

calf veins -

anterior tibial vein, posterior tibial vein, peroneal vein

Question 4

Distal DVT - Mx

Answer 4

1. watch and wait, (40% have simulatanous PE at dx, 25% untreated cases extend proximally within a week)

OR
2. treat with NOAC for 6-12weeks

Question 5

? DVT - initial assessment / treatment decision pathway

Answer 5

Hx and examination

• RF
• hx, swollen, tender, erythematous leg.

perform Well’s criteria for DVT
Wells criteria:
low risk (0) - d dimer to exclude
mod risk (1-2) - high sense d dimer +/- venous doppler USS (compression ultrasonography)
high risk (3) - venous doppler USS (compression ultrasonography)

mod probability/risk - d dimer positive and doppler neg, repeat doppler in 1 week

mod-high probability - doppler uss negative, consider pelvic vein thrombosis and do a CT angio.

high clinical suspicion of DVT and no immediate access confirmatory testing available - commence
empirical anticoagulation LMWH (enoxaparin 1.5mg/kg subcut od)

Question 6

PE and haemodynamically unstable - MX

Answer 6

DRABCDE
Fibrinolysis - ateplase 10mg IV stat, then 90mg/2hrs
tenecteplase 30mg IV bolus

Question 7

DVT - strong clinical risk factors (6)

Answer 7

injury

• fracture hip or lower limb
• spinal cord injury
• major trauma

surgeries

• hip or knee replacement surgery
• major general surgery
• prior history of DVT (that’s what ACI says but not RACGP)

Question 8

DVT - moderate clinical risk factors (4)

Answer 8

oestrogen

• hormone therapy ( OCP or HRT )
• post-partum pregnancy

not moving

• arthroscopic knee surgery
• paralytic stroke
• prior VTE (ACI says its strong, RACGP says moderate)

Question 9

DVT - weak clinical risk factors (4)

Answer 9

• immobilisation ( bed rest > 3 days or air travel > 8 hours)
• antepartum pregnancy
• obesity
• advancing age

Question 10

DVT

• clinical signs and symptoms (3)
• examination findings (4)

Answer 10

hx

• swelling in limb
• tenderness in limb
• warmth in limb

ex

• collateral nonvaricose superficial veins present
• calf swelling >3cm in affected leg, measured 10cm below tibial tuberosity
• tenderness along deep venous system
• pitting oedema in affected leg

Question 11

DVT - ddx (5)

Answer 11

• dermatitis
• cellulitis
• phlebitis
• muscle strain
• ruptured Baker’s cyst

Question 12

DVT

• what does wells score for DVT assess
• 3 possible results from a well’s score

Answer 12

• pre-test probability of patient having a DVT
• 0 means low risk
• 1-2 means moderate risk
• 3 or more means high risk

Question 13

DVT - clinical signs and symptoms - how to measure calf circumference

Answer 13

circumference as measured 10cm below tibial tuberosity

Question 14

suspected DVT - when should you do standard d-dimer testing

Answer 14

wells score for DVT 0

Question 15

suspected DVT - when should you do high sensitivity d-dimer testing

Answer 15

wells score for DVT 1-2

Question 16

suspected DVT - when is a d-dimer test not useful

Answer 16

wells score for DVT >= 3

Question 17

suspected DVT - when to request ultrasound

Answer 17

wells score for DVT >=3

+ve d-dimer test

Question 18

suspected DVT - what type of ultrasound to request

Answer 18

compression ultrasonography of leg

Question 19

suspected DVT - additional imaging to consider if ultrasound negative, but mod-high probability

Answer 19

CT angiography

Question 20

What patient population is Well’s criteria for DVT designed for (2)

Answer 20

• outpatients with ? DVT

- ED patients with ? DVT

Question 21

What is the PERC rule? Which patient criteria does it apply to

Answer 21

Pulmonary Embolism Rule-Out criteria
- if its negative, PE unlikely

use in patients where pre-test probability < 15%