Pulmonary Embolism: The Clot Thickens, Part 1

 
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30% of Americans who have DVTs end up having long term complications. 100,000 people in America die from PEs every single year, 30% of those die within 30 days of diagnosis and 1/4 of people that present with PE sudden death is the very first symptom

Beginning your Work Up

 
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risk factors

Virchow’s Triad

  • Venous Stasis: long plane rides, ventricular dysfunction, venous insufficiency (PVD), previous clot already there

  • Hypercoagulability: pregnancy, cancer, estrogen therapy, thrombophilia, acute inflammatory disorders (i.e. sepsis)

  • Endothelial Injury: surgery, trauma, blood draws, atherosclerotic disease

Unilateral leg swelling

Unilateral leg swelling

DVT

  • Telltale sign: unilateral swelling - it’s going to be “swole”

  • The most sensitive exam is measuring the calf; 10cm down from tibial tuberosity, measure across - if there is a discrepancy of 3cm its very sensitive and specific for DVT

Deep Veins vs. Superficial Veins

  • Deep Veins LE: popliteal, common iliac, posterior and anterior tibial, superficial femoral, external iliac

Work-up

  • Pretest probability: you have some index of suspicion that the patient has a disease (e.g. you aren’t ordering CTAs on all your acute bronchitis patients)

  • Once you are suspicious for PE:

    • Calculate Wells Score (separate calculation for PE or DVT): you will get low, moderate, or high risk for PE

      • If you are moderate or high risk of VTE - your pre-test probability is high enough for PE that you need to test for something to rule it out. Back in the day that was a d-dimer (sensitive but not specific) - now we look at PERC criteria

      • If all the PERC criteria are negative, your pre-test probability for PE is less than 1%. That’s better than d-dimer

        • A way to remember PERC criteria - use the mnemonic HADCLOTS

          • Hormone use, age >= 50, DVT or PE history, coughing up blood, leg swelling, O2 sat<95%, tachycardia, surgery

  • If they are moderate/high risk on wells criteria and they failed PERC criteria, THEN you order d-dimer

    • If this is positive hen you consider additional testing/imaging modalities

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