DVT / PE

Question 1

What are the risk factors for a VTE

Answer 1

immobilitiy
active malignancy
pregnancy
obesity

SPASMODICAL
Sex - female
Pregnancy 
Age - increase
Surgery 
Malignancy
Oestrogen - OCP or HRT
DVT/PE hx
Immobility 
Colossal size - obesity
Antiphoshpholipid antibodies
Lupus anti-coagulant ( an antiphosphpholipid antibody)

Question 2

Symptoms of PE

Signs

Answer 2

Dyspnoea
pleuritic chest apin
haemoptysis
syncope

signs 
fever
cyanosis
tachycardia, tachypnoea
RHF - hypotension, elevated JVP 
Evidence of DVT

Question 3

What is WELLS score?

Answer 3

Number used to predict a person’s risk of having a DVT based on clinical features.
There is a modified wells score criteria for risk of PE.
score of 3+ = high test probability and should be treated as suspected DVT and perform compression US.
1-2 points = intermediate retest probability - treat as suspected DVT and perform compression US
0 or less - low pretest prob for DVT - perform D dimer, if + then treat as suspected DVT, if - can reliably exclude DVT.

Question 4

What can be done to prevent a VTE?

Answer 4

• all patients should have a risk assessment on admission
• TEDs
• Prophylactic LMWH ( 40mg enoxaparin sub cut every 24hrs)
  note - therapeutic dose would be 1.5mg/kg/24hrs
• avoid OCP or HRT if at risk

Question 5

Management of a PE

Answer 5

Sit up, give O2
Analgesia
If critically ill with massive PE consider thrombolysis
LMWH heparin therapeutic dose enoxaparin 1.5mg/kg/24hrs SC

TEDS
continue LMWH until INR 2-3

Question 6

What does Wells score for DVT take into account?

Answer 6

• chemo in last 6months
• immobilised leg
• major surgery or bedridden >3days past month
  local tenderness
  entire leg swollen
  calf swelling >3cm compared to ssymptomatic leg
  pitting oedema
  collateral superficial veins ( non varicose)
  if an alternative diagnosis seems more likely then -2 points

for PE - also haemoptysis and tachycardia

Question 7

What are the clinical signs of DVT?

Answer 7

Calf warmth / tenderness/ swelling/ erythema
Fever
pitting oedema
Homan’s sign

Question 8

What is Homan’s sign?

Answer 8

Resistance or pain on forced foot dorsiflexion

**this should not be tested as it may dislodge a thrombus

Question 9

What are the differentials for patient with swollen calves

Answer 9

• • fever, tenderness, erythema -> DVT, Cellulitis
• Heart failure
• Nephrotic syndrome
• Liver failure

Question 10

Investigations in patient with suspected PE

Answer 10

FBC - anaemia, infection - may not be a PE
PT time and INR low
ABG - normal or may be acidotic with low PaO2 and PaCo2
CXray - normal or oligaemia ( due to occlusion o vessel)
ECG - sinus tachy
Doppler US of thigh and pelvis look for DVT
CTPA ( or VQ scan is alternative for pregnancy)

Question 11

Treatment of PE

Answer 11

Anticoagulate them
1st line LMWH - subcutaneous ( IV version is toxic)
- therapeutic - 1.5mg/kg/day. ( or 1mg/kg/bd for high risk or very obese)
- prophylactic - 40, 20 for CKD of frail + low weight

then send home on DOAC
for 3 months if provoked
for 6 months if unprovoked ( and send bloods to check antiphospholipids to explain why they had the clot)
recurrent = lifelong DOAC

warfarin takes 72hrs, doacs take 24hrs so must use LMWH to bridge them and stop the clot getting bigger

Question 12

investigations needed in order to get CTPA

Answer 12

To get CTPA
- Need high d dimer
- Need to know renal function
Need to know wells score