Deep Vein Thrombosis (DVT) Pulmonary Embolism (PE)
Definition: a DVT is a clot that usually develops in one of the deep veins Definition occlusion of the pulmonary vasculature by a clot.
(running between muscles). Usually occurs in the lower leg Aetiology DVT, air/fat embolus, amniotic fluid embolus, foreign body via
Pathophysiology Virchow’s triad IVDU
1. Hypercoagulability malignancy, surgery, trauma, OCP, clotting Signs + symptoms
abnormalities 1. Chest pain (pleuritic)
2. Venous stasis immobility e.g. after surgery, pregnancy, heart failure 2. Dyspnoea
3. Endothelial damage inflammation, previous thrombosis 3. Haemoptysis
+ Tachpnoea
DDx A MSK injury Baker’s cyst rupture Cellulitis + Tachycardia
Signs + symptoms
Lower limb pain (typically calf pain) Risk factors ‘SPASMODICAL’
Tenderness along the line of deep veins Sex: F Pregnancy Age (older) Surgery Malignancy Oestrogen: OCP/HRT
Swelling/pitting oedema DVT/previous Hx Immobility Colossal size Antiphospholipid Lupus anti-
Erythema coagulant
Engorgement of superficial veins
Dx Well’s score
Dx Two-level Well’s score Clinical feature Points Mx
Clinical feature Points Mx
Minimum leg swelling + pain w/ palpation of deep 3
Active cancer 1 veins
Paralysis, paresis, plaster immobilisation 1 Alternative diagnosis less likely 3 > 4 points
Bedridden for 3 days, major surgery w/i 12 weeks 1 HR >100 1.5 PE likely
≥ 2 points
Localised tenderness along distribution 1 Immobilisation for 3 days/ surgery in the past 4 1.5
DVT likely
Entire leg swollen 1 weeks < 4 points
Calf swelling >3cm than asymptomatic side 1 Previous DVT/PE 1.5 PE unlikely
≤ 1 point Haemoptysis 1
Pitting oedema 1
Collateral superficial veins (non-varicose) 1
DVT unlikely Malignancy 1
Previous DVT -2
Alternative Dx -2 Mx
>4 CTPA (unless pregnancy/renal problems V/Q scan)
Mx Delay? Give LMWH until then
Well’s score positive proximal leg vein USS w/I 4hrs negative D- <4 D-dimer (95-98% specificity):
Dimer Positive Do CTPA
If leg vein USS cannot be carried out D-dimer USS should be Negative No Rx
performed w/I 24hrs (Give LMWH until then) LMWH e.g. Enoxaparin/ Fondaparinux
LMWH or Fondaparinux (continued for 5 days or until target INR 2-3 is Massive PE thrombolysis use unfractionated
achieved), patients w/ active cancer LMWH for 6 months + Vitamin K antagonist e.g. Warfarin should be given w/i 24hrs
+ Warfarin w/i 24hrs of Dx (continued for 3 months/ longer than 3 months LMWH/Fondaparinux 5 days/until target INR 2-3
in unprovoked DVT) Warfarin 3 months
Definition: a DVT is a clot that usually develops in one of the deep veins Definition occlusion of the pulmonary vasculature by a clot.
(running between muscles). Usually occurs in the lower leg Aetiology DVT, air/fat embolus, amniotic fluid embolus, foreign body via
Pathophysiology Virchow’s triad IVDU
1. Hypercoagulability malignancy, surgery, trauma, OCP, clotting Signs + symptoms
abnormalities 1. Chest pain (pleuritic)
2. Venous stasis immobility e.g. after surgery, pregnancy, heart failure 2. Dyspnoea
3. Endothelial damage inflammation, previous thrombosis 3. Haemoptysis
+ Tachpnoea
DDx A MSK injury Baker’s cyst rupture Cellulitis + Tachycardia
Signs + symptoms
Lower limb pain (typically calf pain) Risk factors ‘SPASMODICAL’
Tenderness along the line of deep veins Sex: F Pregnancy Age (older) Surgery Malignancy Oestrogen: OCP/HRT
Swelling/pitting oedema DVT/previous Hx Immobility Colossal size Antiphospholipid Lupus anti-
Erythema coagulant
Engorgement of superficial veins
Dx Well’s score
Dx Two-level Well’s score Clinical feature Points Mx
Clinical feature Points Mx
Minimum leg swelling + pain w/ palpation of deep 3
Active cancer 1 veins
Paralysis, paresis, plaster immobilisation 1 Alternative diagnosis less likely 3 > 4 points
Bedridden for 3 days, major surgery w/i 12 weeks 1 HR >100 1.5 PE likely
≥ 2 points
Localised tenderness along distribution 1 Immobilisation for 3 days/ surgery in the past 4 1.5
DVT likely
Entire leg swollen 1 weeks < 4 points
Calf swelling >3cm than asymptomatic side 1 Previous DVT/PE 1.5 PE unlikely
≤ 1 point Haemoptysis 1
Pitting oedema 1
Collateral superficial veins (non-varicose) 1
DVT unlikely Malignancy 1
Previous DVT -2
Alternative Dx -2 Mx
>4 CTPA (unless pregnancy/renal problems V/Q scan)
Mx Delay? Give LMWH until then
Well’s score positive proximal leg vein USS w/I 4hrs negative D- <4 D-dimer (95-98% specificity):
Dimer Positive Do CTPA
If leg vein USS cannot be carried out D-dimer USS should be Negative No Rx
performed w/I 24hrs (Give LMWH until then) LMWH e.g. Enoxaparin/ Fondaparinux
LMWH or Fondaparinux (continued for 5 days or until target INR 2-3 is Massive PE thrombolysis use unfractionated
achieved), patients w/ active cancer LMWH for 6 months + Vitamin K antagonist e.g. Warfarin should be given w/i 24hrs
+ Warfarin w/i 24hrs of Dx (continued for 3 months/ longer than 3 months LMWH/Fondaparinux 5 days/until target INR 2-3
in unprovoked DVT) Warfarin 3 months
