DVT / PE

What symptoms would a patient complain of if they had a DVT? 

Pain (usually unilateral calf) SIN = severe!
*When you see a lot of orthopaedic surgery like TKR, THR you get a good feel for what is the typical amount of pain. In my experience people with DVT have a profound level of pain.

S = Severe
I = High
N = Inflammatory (cardinal signs dolor, tumor, rubor,
Quality = Heavy ache

Clinical point: 
Always ask questions and examine a suspected DVT with suspicion of PE
e.g. Any SOB, chest pains, low SATS?

OBS: Dilated superficial veins, calf redness, discolouration, lower limb swelling
PALPATION: Pitting oedema, tenderness and firmness on palpation of the calf
SPECIAL TESTS: +ve Homan’s Sign

What would you do if a patient you were seeing presented with these symptoms?

Inpatient on the ward:
Escalate to nurse / RMO / consultant

Outpatient: 
Urgent GP referral for further Ix
A+E if suspected PE

Patients can be divided into “DVT unlikely” and “DVT likely” groups based on Wells score. An additional moderate risk group can be added based on the sensitivity of the d-dimer being used.

• A score of 0 or lower is associated with DVT unlikely with a prevalence of DVT of 5%.
  • These patients should proceed to d-dimer testing:
    • A negative high or moderate sensitivity d-dimer results in a probability <1 and="" further="" imaging="" is="" li="" no="" required.="">
    • A positive d-dimer should proceed to US testing.
      • A negative US is sufficient for DVT rule out.
      • A positive US is concerning for DVT; strongly consider treatment with anticoagulation.

• A score of 1-2 is considered moderate risk with a pretest probability of 17%.*
  • These patients should proceed to high-sensitivity d-dimer testing (moderate sensitivity d-dimer is not sufficient).
    • A negative high-sensitivity d-dimer is sufficient for rule out of DVT in a moderate risk patient with a probability of <1 li="">
    • A positive high sensitivity d-dimer should proceed to US testing.
      • A negative US is sufficient for ruling out DVT.
      • A positive US is concerning for DVT, strongly consider treatment with anticoagulation.

• A score of 3 or higher suggests DVT is likely. Pretest probability 17-53%.
  • All DVT likely patients should receive a diagnostic US.
  • D-dimer testing should be utilized to help risk-stratify these DVT-likely patients.
    • In DVT likely patients with negative d-dimer:
      • A negative US is sufficient for ruling out DVT, consider discharge.
      • A positive US should be concerning for DVT, strongly consider treatment with anticoagulation.
    • In DVT likely patients with a positive d-dimer:
      • A positive US should be concerning for DVT, strongly consider treatment with anticoagulation.
      • A negative US is still concerning for DVT. A repeat US should be performed within 1 week for re-evaluation.