For today:

1. Define and discuss the indications for the following diagnostic studies:
a. d-DIMER ASSAY
Includes the latex agglutination and ELISA D-dimer tests. ELISA is more sensitive. Both
are not very specific so a negative test rules out clots but a positive test does not rule in
a PE/DVT. D-dimer can be increased with recent surgery, a recent MI, sepsis and other
chronic illnesses. A positive DVT must be further investigated. In >90% of patients with a
PE the ELISA D-dimer will be >500 ng/mL.

D-dimer should be used in patients with a low pre-test probability for PE/DVT since a
negative test will rule out a thromboembolism in most cases.

b. VENOUS DUPLEX ULTRASONOGRAPHY

US is the test of choice for lower extremity DVTs. It has a high sensitivity and specificity
(95% for both). The sensitivity is lower for obese patients and patients with isolated calf
embolisms. Patients with signs of a PE and a positive duplex US can be assumed to have
a PE.
US should be used for a patient with signs and symptoms of a DVT (unilateral leg
swelling, warm, cyanotic extremity, etc). However, US is not the best test for PE. It
should only be used if there are signs and symptoms of DVT and PE together and the
patient cannot undergo other imaging tests (pregnancy, renal failure/disease, contrast
allergy).

c. VENTILATION AND PERFUSION (V/Q) SCAN

V/Q scans compare the emission of radioisotopes from the PA to the alveoli indicating
perfusion. Only 1/3 of scans are sufficient to rule out a PE. V/Q scans should only be
used on patients that cannot undergo CTPA and do not have evidence of a DVT that can
be imaged with US or if US is inconclusive.

d. COMPUTED TOMOGRAPHY PULMONARY ANGIOGRAPHY (CTPA)

CTPA is the test of choice. Using a lower extremity run-off you can also find LE
embolisms. The sensitivity is ~90% and the specificity is 95%. CT can also find other
pathologies that may be presenting as a PE instead. This test should only be done in HD
stable patients though. It is also CI if the patient cannot withstand contrast (renal
failure) or if the patient cannot be exposed to radiation (pregnancy).

e. PULMONARY ANGIOGRAPHY
Angiography is the best test however it is not used much because it is invasive and time
consuming. It requires catheterization into the PA and contrast. It can image very small
filling defects in small vessels the best. However, it is a long procedure, it is not always
available and the patient must be able to undergo radiation and contrast. It can also
cause cardiac arrythmias due to the catheterization and perforation of the PA.

2. Discuss the Wells Criteria for both PE and DVT.

The Well’s Criteria calculates the pre-test probability of a patient having a PE or DVT based on
which criteria you use. There are Well’s criteria for PE and DVT. It groups patients into low-,
moderate- or high-risk. Low-risk, is ≤4 and ≥4 is high-risk for DVT.
However, for PE the high-risk group is ≥6, moderate-risk is 2-6, and low-risk is ≤ 2 points.
Based on the risk levels for each group determines what testing/imaging you should choose.
For example, patients with low risk should get a D-dimer. If the D-dimer is negative the
probability of a PE is low.

3. What is the appropriate treatment for PE?

The appropriate treatment for PE depends on the HD stability of the patient, risk of bleeding,
and the size of the embolus.
First is always ABCs and supportive therapy. Supplemental O2 if needed, IVF/vasopressors if
hypotensive, and cardiac monitoring.
Then if the patient’s risk of bleeding is low and not CI empiric anticoagulation should be used.
Absolute CI to anticoagulation therapy are: recent surgery, hemorrhagic stroke, and active
bleeding.
Choosing the anticoagulant depends on if the patient is going to be outpatient or inpatient and
if the patient/family can give subcutaneous injections. Otherwise you could start a LMWH
bridge to Warfarin. You could also use rivaroxaban which is FDA approved to treat DVT and PE.

Patients with massive or sub-massive PE’s should receive fibrinolysis therapy. A massive PE is
defined as a systolic blood pressure <90 mm Hg. Patients with a submassive PE will have
evidence or right ventricular dysfunction, elevated troponin or B-type natriuretic peptide, or
persistent hypoxemia with distress.

CI to fibrinolysis or thrombolytic therapy include uncontrolled hypertension at presentation,

recent major surgery or trauma (past 3 weeks), metastatic cancer and head injury. Patients with
a head injury should get a CT first. Alteplase is the drug of choice for PEs.
4. What preventative measures should be taken in a patient with paraplegia?

“Deep vein thrombosis (DVT) is a common complication of traumatic spinal cord injury,”
UptoDate. Recent paraplegics and patients with spinal cord injuries are high risk for VTEs.
LMWH as DVT prophylaxis in the hospital can prevent he formation of VTEs. Studies suggest
that LMWH should be initiated within 72 hours of acute spinal cord injury if possible to prevent
formation of DVT/PE. The duration of treatment should be from 8-12 weeks for patients with
complete motor injury.

The patients should also have mechanical prevention such as compression stockings—or SCDs
while in the unit. Regular ROM exercises can also help prevent the formation of DVTs and their
sequelae.

Sources:
Tintinalli’s Emergency Medicine A Comprehensive Study Guide, 8th edition
Tintinalli’s Emergency Medicine Manual, 7th Edition

First Aid for the Wards

A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury:
Recommendations on the Type and Timing of Anticoagulant Thromboprophylaxis
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5684841/

Prevention of Thromboembolism in Spinal Cord Injury

https://emedicine.medscape.com/article/322897-overview#a6
Good morning everyone! For today's assignment, please answer the following four multiple
choice questions and include an explanation of why the answer you chose is correct.
Comprehension Questions
Question 1 of 4
Which of the following statements regarding DVT is most accurate?
A. A patient with thrombosis of the superficial femoral vein is never at risk for PE.
B. Venography is the definitive test for the diagnosis of DVT.
C. Thrombosis of the vena cava, subclavian veins, and right atrium are frequent sources of
PE.
D. Venous duplex ultrasonography is most useful in diagnosing DVT in the pelvic veins.
E. Cancer successfully treated 5 years ago is associated with a higher risk for DVT.
Venography is the definitive test for DVT however it is invasive and requires contrast so
a US is the most used test. US is not effective in obese patients or patients with a
suspected DVT in deep veins or the pelvis.
Question 2 of 4
A 52-year-old healthy man presents with a 3-day history of a pleuritic chest pain and SOB. He
has normal vital signs and physical examination. Which test is most useful in ruling out
pulmonary emboli in this patient?
A. Electrocardiogram (ECG)
B. Chest x-ray
C. Arterial blood gas (ABG)
D. d-dimer level
E. Oxygen saturation
Patient’s with a low clinical suspicion for VTE should get a D-dimer to rule out VTE. In most
cases if it is negative the patient likely does not have a VTE. CXR, ECG, and ABG are good
baseline labs to get on any patient with these symptoms but does not effectively rule in or out a
VTE.
“Patients with PE may be in respiratory failure despite an oxyhemoglobin saturation of ≥90%.”
O2 saturation is a requirement for the pulmonary embolism severity index (PESI) but is not
always sufficient to rule in or out a PE.

Question 3 of 4
Which of the following patients with shortness of breath has the lowest clinical probability for
PE?
A. A 67-year-old man who underwent bilateral total knee replacements 2 weeks ago.
B. A 38-year-old man who underwent an uncomplicated open appendectomy 3 weeks ago.
C. A 35-year-old woman undergoing treatment for ovarian cancer.
D. A 35-year-old man with a history of a DVT 15 years ago, which occurred after an
accident.
E. A 26-year-old woman who had an uncomplicated vaginal delivery 10 days ago.
Women who are pregnant are at a higher risk of developing a PE/DVT than a non-pregnant
woman. They are increased risk of developing a VTE for up to 6 weeks after delivery.
However, this risk is low. Even in women with a previous hx of VTE during their risk during
pregnancy is ~2%. Meanwhile patients over the age of 50, have a history of VTE, malignancy
 and recent complex surgery with general anesthesia are at an increased risk of developing
VTE.
Question 4 of 4
A 57-year-old man presents to the ED complaining of sudden onset of shortness of breath with
pleuritic chest pain. He was recently released from the hospital after being diagnosed with
lymphoma. He had an indwelling catheter placed in his left subclavian vein the day before for
chemotherapy administration. He was previously healthy without significant medical history.
His vital signs are heart rate of 105 beats per minute, blood pressure of 126/86 mm Hg,
respiratory rate of 28 breaths per minute, and O2 saturation of 100% on room air. The breath
sounds are clear bilaterally. His heart sounds are normal without an S 3 or S4 gallop. His left arm
is mildly edematous but otherwise painless, with a normal pulse examination. There is no
swelling of his lower extremities, and he has no pain with palpation of his calves. His catheter
incision site is clean and intact. Which of the following studies is inappropriate for this patient?
A. Chest x-ray
B. ECG
C. Contrast CT scan of the chest
D. d-dimer assay
E. Duplex ultrasonography of the deep veins of the upper and lower extremities

Getting a D-dimer in this patient is inappropriate because the patient has a high clinical
suspicion for an UE DVT and PE. This patient has signs and symptoms of an UE DVT and PE. This
patient also has multiple risk factors for developing a DVT/PE including recent surgery, PIC line,
and malignancy. Therefore, this patient should get a CTPA while the patient is stable. A D-dimer
is also going to be affected by the patient’s recent surgery and diagnosis of cancer both of
which can falsely elevated a D-dimer.

Is oxygen saturation variable of simplified pulmonary embolism severity index reliable for
identification of patients, suitable for outpatient treatment
https://onlinelibrary.wiley.com/doi/abs/10.1111/crj.12591

UptoDate

Deep venous thrombosis in pregnancy: incidence, pathogenesis and endovascular

management
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5778511/