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Pulmonary Embolism & Deep Vein Thrombosis (Primary Survey (Breathing:…
Pulmonary Embolism & Deep Vein Thrombosis
Primary Survey
Breathing: RR, SpO2, listen to breath sounds, provide oxygenation as needed, CXR
Circulation: HR, BP, cap refill, IV access, Bloods (FBC, UEC, VBG/ABG, coags, group and save, hold), fluid resus, analgesia, ECG
Airway: Is it patent?
Disability: AVPU/GCS, pupils, BGL
DRS: consultant
Exposure: Temp, examine calves
Investigations
Doppler U/S of calf
CTPA/VQ scan
D-dimer
Criteria
PERC (HADCLOTS)
DVT/PE History
Coughing blood
Leg swelling
O2 < 95%
Tachycardia > 100
Age > 50
Hormone (OCP)
Surgery/Trauma < 28days
Score of 0 makes PE unlikely
Well's criteria for DVT
Active malignancy
Localised tenderness along the deep venous system
Collateral superficial veins present
Previous DVT
Entire leg swollen
Surgery within 4 week for bedridden recently for 3 days
Calf swelling >3cm compared to the other leg
Unilateral pitting oedema
Paralysis, paresis or recent plaster immobilisation of the lower extremity
Alternate diagnosis as/more likely (-2)
Score </= 2: Moderate risk, perform high sensitivity D-dimer; score >2: High risk, perform an U/S
Well's criteria for PE
Tachycardia >100 BPM (1.5)
Signs and symptoms of DVT (3)
Haemoptysis (1)
PE likely (3)
Previous Hx of PE/DVT (1.5)
Immobilisation/surgery in the last 4 weeks (1.5)
Malignancy (1)
Score </= 4 perform D-dimer (some physicians use PERC for scores </= 2) to rule out PE, if score > 4 proceed straight to CTPA/VQ scan
Further management
Stable
Anticoagulation
(2nd) Warfarin: target INR 2-3, give IV heparin/LMWH for first 5 days (pt with poor renal function)
IV enoxaparin or dalteparin (if associated with pregnancy/cancer)
IV unfractionated heparin 5000 units (if asociated with poor renal function or increased risk of bleeding)
(1st) NOAC e.g. apixaban or rivaroxaban (ensure adequate renal function- Cr > 30)
Unstable
Consult respiratory physician regarding thrombolysis with alteplase/tenecteplase or interventional clot retrieval (surgical thrombectomy), followed by LMWH
Maintain oxygen > 95%
Consider use of vasopressors
Long term
Unprovoked: at least 3 months, then definitely reassess
Provoked: 3 months, then consider reassessing
Consider screening for bleeding disorders if strong suspicion
Distal DVT: consider Rx. If treating: 6 weeks
Prophylaxis: 5000U LMWH