PE:

D-dimer level has NO positive predictive value

A negative d-dimer has a high negative predictive value
Normal Ddimer levels exclude PE in >30% of cases

Wellscriteria/scoringforPE
Present

Score

ClinicalSignsandSymptomsofDVT?

+3

PEisNo.1DxorEquallylikleyDx

+3

HeartRate>100

+1.5

Immobilizationatleast3days,orSurgeryinthePrevious4weeks

+1.5

5Previous,objectivelydiagnosedPEorDVT?

+1.5

Haemoptysis?

+1

Malignancywithtreatmentwithin6months,orpalliative?

+1

PretestclinicalprobabilityofaPE:
WellsScore>4PElikely.Considerdiagnosticimaging.
WellsScore4orlessPEunlikely.ConsiderDdimertoruleoutPE.

WellsCriteria/scoringforDVT
Present

Score

Lowerlimbtraumaorsurgeryorimmobilisationinaplastercast

+1

Bedriddenformorethanthreedaysorsurgerywithinthelastfourweek

+1

Tendernessalonglineoffemoralorpoplitealveins(NOTjustcalftenderness)

+1

Entirelimbswollen

+1

Calfmorethan3cmbiggercircumference,10cmbelowtibialtuberosity

+1

Pittingoedema

+1

Dilatedcollateralsuperficialveins(nonvaricose)

+1

PastHxofconfirmedDVT

+1

Malignancy(includingtreatmentuptosixmonthspreviously)

+1

Intravenousdruguse

+3

AlternativediagnosisasmorelikelythanDVT

PretestClinicalprobabilityofaDVTwithscore:

DVT"Likely"ifWell's>1
DVT"Unlikely"ifWells<2
Gold standard: CT angiogram

TIMIScoreCalculation(1pointforeach):

Age>=65

Aspirinuseinthelast7days(patientexperienceschestpaindespiteASAuseinpast7days)

Atleast2anginaepisodeswithinthelast24hrs

STchangesofatleast0.5mmonadmissionEKG

Elevatedserumcardiacbiomarkers

KnownCoronaryArteryDisease(CAD)(coronarystenosis>=50%)

Atleast3riskfactorsforCAD,suchas:Hypertension>140/90oronantihypertensives,current
cigarettesmoker,lowHDLcholesterol(<40mg/dL),diabetesmellitus,Familyhistoryof
prematureCAD(CADinmalefirstdegreerelative,orfatherlessthan55,orfemalefirstdegree
relativeormotherlessthan65).

ScoreInterpretation:
%riskat14daysof:allcausemortality,neworrecurrentMI,orsevererecurrentischemiarequiringurgent
revascularization.
Scoreof01=4.7%risk
Scoreof2=8.3%risk
Scoreof3=13.2%risk
Scoreof4=19.9%risk
Scoreof5=26.2%risk
Scoreof67=atleast40.9%risk

Persistenthypotensionorshock(ie,asystolicbloodpressure<90mmHgoradecreasein
thesystolicbloodpressureby40mmHgfrombaseline)duetoacutePEistheonly
widelyacceptedindicationforsystemicthrombolysis
Alsoindicatedforptwith:

ECHOshowingRtventriculardysfunctionwithouthypotension.IndicatedbyRVsystolic
pressure>3040mmHg
DVT
Contraindicationstothrombolysis:
Absolute:
intracranialsxordisease
Recent internal bleeding
Relative CI:
Thrombocytopenia
Uncontrolled HTN
CPR
Pregnancy
Hypercoaguable workup:
MCC: FVL (leads to activated protein C resistance)
Prothrombin G20210A mutation
24 F OCPs, smoking
DVT in outpt clinic
Do PE workup
Can send home on Lovenox
>55y + >30pack yrs screen with low radiation chest CT
Prostate CA screen:
>50yo
annual DRE, offer PSA annually
Ovarian CA screen:
No screening recommended unless history of malignant syndrome
4% are familial
Breast CA:
Adjunct MRI for 1st degree family member with BRCA or identified
BRCA mutation

CA prevention of PROVEN benefit

Lung: smoking cessation counseling
Ovarian: OCP
Microcytic hypochromic anemia
Poikolocytosis
AnkylocytosisIron def has both different size and shapes
Thalassemias different sizes