DVT/PE

Question 1

Typical signs and symptoms of DVT

Answer 1

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

Question 2

Tool to assess likelihood of DVT

Answer 2

two-level DVT Wells score

Question 3

Which patients should be referred for same-day assessment if DVT is suspected

Answer 3

In a woman who is pregnant or has given birth within the past 6 weeks

Question 4

Next steps of management for patients who are likely to have DVT based on Wells score

Answer 4

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

Question 5

Next steps of management for patients who are unlikely to have DVT based on the results of two-level DVT Wells score

Answer 5

Offer a D-dimer test with results available within 4 hrs

Offer interim therapeutic anticoagulation while awaiting the result

Question 6

Management if D-dimer test is positive

Answer 6

Offer a proximal leg vein ultrasound with the results available within 4 hrs if possible

Interim anticoagulation while waiting

Question 7

Management if D-dimer test is negative

Answer 7

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

Question 8

First line and second line interim therapeutic anticoagulation for suspected DVT

Answer 8

Offer apixaban or rivaroxaban first line

LMWH followed by dabigatran or vitamin K antagonist for at least 5 days if above are not appropriate

Question 9

Tests which should be carried out for people starting interim anticoagulation therapy

Answer 9

Baseline blood tests including FBC, renal and hepatic function, prothrombin time(PT), and APTT

Question 10

Maintenance treatment for people with a confirmed DVT

Answer 10

Oral anticoagulant(warfarin, apixaban, dabigatran etc) following acute treatment

Question 11

How long is maintenance treatment usually continued for DVT

Answer 11

For at least 3 months, but duration may be longer depending on whether DVT was unprovoked or provoked

Question 12

Usual INR target for patients being treated with warfarin

Answer 12

Target of 2.5, keeping within the range of 2.0-3.0

Question 13

What should be investigated in patients with unprovoked DVT

Answer 13

Possibility of an undiagnosed cancer if they are not already known to have cancer

Thrombophilia testing as appropriate

Question 14

When should you suspect a PE

Answer 14

Dyspnoea
Tachypnoea
Pleuritic chest pain
Features of DVT including leg pain and swelling(usually unilateral), lower abdominal pain, redness, increased temperature, and venous distension

Question 15

Risk factors for PE

Answer 15

DVT 
Previous VTE 
Active cancer 
Recent surgery 
Significant immobility 
Lower limb trauma or fracture 
Pregnancy

Question 16

Complications of PE

Answer 16

Death
Hypotension(clinically massive PE)
Chronic thromboembolic pulmonary hypertension
Right heart failure

Question 17

When should you suspect a PE

Answer 17

Dyspnoea 
Tachypnoea 
Pleuritic chest pain 
\+/- Features of DVT including leg pain and swelling(usually unilateral) 
Lower abdo pain 
Redness 
Increased temperature 
Venous distension

Question 18

Signs of PE

Answer 18

Tachycardia 
Hypoxia 
Pyrexia 
Elevated JVP 
Gallop rhythm 
Pleural rub 
Hypotension

Question 19

CXR features that may be present in a PE

Answer 19

Atelectasis
Pleural effusion
Elevation of a hemidiaphragm

Question 20

ECG signs indicative of a PE

Answer 20

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

Question 21

When should you arrange immediate admission for people with suspected pulmonary embolism

Answer 21

Signs of haemodynamic instability(pallor, tachycardia, hypotension, shock and collapse)

Pregnant or have given birth within past 6 weeks

Question 22

Which scoring system can be used to assess likelihood of a PE

Answer 22

Two-level PE Wells score

Question 23

Management of patients with a Wells score of more than 4 points(PE likely)

Answer 23

Arrange hospital admission for CTPA

Offer interim therapeutic anticoagulation if CTPA cannot be carried out immediately

Question 24

Management of patients with a Wells score of less than 4 points(PE unlikely)

Answer 24

D-dimer test with interim therapeutic anticoagulation while awaiting the result

If positive, arrange for immediate CTPA

Question 25

1st line interim therapeutic anticoagulation - PE

Answer 25

Offer apixaban or rivaroxaban LMWH if not

Question 26

Appropriate baseline tests for people starting interim anticoagulation therapy

Answer 26

FBC Renal and hepatic function Prothrombin time APTT

Question 27

Which investigation may be useful in pregnant women with a suspected PE

Answer 27

Lower limb compression venous ultrasound

Question 28

Pharmacological options for confirmed PE

Answer 28

LMWH Fondaparinux Unfractionated heparin Oral anticoagulant treatment

Question 29

Mechanical(or physical) interventions in PE management

Answer 29

IVC filters | Thrombolytic therapy

Question 30

Examples of pharmacological thrombolytics

Answer 30

Streptokinase Urokinase rt-PA

Question 31

VTE risk factors

Answer 31

``` advancing age obesity family history of VTE pregnancy (especially puerperium) immobility hospitalisation anaesthesia central venous catheter: femoral >> subclavian ```

Question 32

Underlying conditions associated with VTE

Answer 32

``` malignancy thrombophilia: e.g. Activated protein C resistance, protein C and S deficiency heart failure antiphospholipid syndrome Behcet's hyperviscosity syndrome ```

Question 33

Medications associated with VTE

Answer 33

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

Question 34

What are thrombophilias

Answer 34

Conditions that predispose patients to blood clots such as: Antiphospholipid syndrome Factor V leiden Antithrombin deficiency

Question 35

Main contraindication for anti-embolic compression stockings

Answer 35

PAD

Question 36

Initial anticoagulation choice for DVT/PE

Answer 36

Apixaban | Rivaroxaban

Question 37

Intervention recommended in patients with a symptomatic iliofemoral DVT

Answer 37

Catheter-directed thrombolysis

Question 38

How long should anticoagulation be continued for

Answer 38

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)

Question 39

What should be investigated in unprovoked DVT

Answer 39

Antiphospholipid syndrome (check antiphospholipid antibodies) Hereditary thrombophilias (only if they have a first-degree relative also affected by a DVT or PE)

Question 40

When is thrombolysis recommended in management of PE

Answer 40

Massive PE where there is circulatory failure(hypotension)

Question 41

Factors considered in two level Wells criteria

Answer 41

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

Question 42

Criteria for PERC rule - to rule out PE

Answer 42

``` Age > 50 HR > 100 O2 sats < 94% Previous DVT or PE Recent surg/trauma Haemoptysis Unilateral leg swelling Oestrogen use(HRT,contraception) ```

Question 43

Interpretation of wells score

Answer 43

PE likely - more than 4 points | PE unlikely - 4 points or less

Question 44

Definition of provoked PE

Answer 44

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.