1st Line investigation for a DVT and PE? Watch

Warrior King
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As the title says. This is confusing.

In my notes which I made for PBL in year 2 (using Oxford Handbook for reference) it says that for a DVT a D-Dimer would be the first line investigation (7th edition mind). It also says a CXR would be the best first line investigation for a PE.

Now in the Oxford Handbook of Clinical Surgery (2nd edition) it says that duplex scan is best for DVT as first line investigation and the CTPA for PE.

However when making notes tonight from "Lecture Notes on General Surgery" (11th edition) it seems to suggest a venography for DVT and CXR for first line investigations.

I'm quite certain that for PE a CTPA would be first-line as it's popped up in MCQs and always the right answer but I'm still confused as to what the definitive investigations are. Can anybody help me out with this or perhaps point me in the right direction e.g. official guidelines or something?

Thanks.
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Ataloss
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(Original post by Warrior King)
As the title says. This is confusing.

In my notes which I made for PBL in year 2 (using Oxford Handbook for reference) it says that for a DVT a D-Dimer would be the first line investigation (7th edition mind). It also says a CXR would be the best first line investigation for a PE.

Now in the Oxford Handbook of Clinical Surgery (2nd edition) it says that duplex scan is best for DVT as first line investigation and the CTPA for PE.

However when making notes tonight from "Lecture Notes on General Surgery" (11th edition) it seems to suggest a venography for DVT and CXR for first line investigations.

I'm quite certain that for PE a CTPA would be first-line as it's popped up in MCQs and always the right answer but I'm still confused as to what the definitive investigations are. Can anybody help me out with this or perhaps point me in the right direction e.g. official guidelines or something?

Thanks.
In terms of Venous Thrombo Embolism (VTE) - the role of a D Dimer is only a rule out for low clinical risk patients! That is the only time it should be used in VTE (it has other uses).

CTPA is the current gold standardinvestigation for diagnosing a PE - but you should work the patient up properly before performing it and obtaining a CXR would naturally be an essential part of this.

Venogram is the most sensitive and specific investigation for the diagnosis of a DVT but has disadvantages. An USS doppler is a good investigation for the diagnosis of a DVT and is more widely used as the initial modality for its diagnosis.
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carcinoma
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(Original post by Warrior King)
As the title says. This is confusing.

In my notes which I made for PBL in year 2 (using Oxford Handbook for reference) it says that for a DVT a D-Dimer would be the first line investigation (7th edition mind). It also says a CXR would be the best first line investigation for a PE.

Now in the Oxford Handbook of Clinical Surgery (2nd edition) it says that duplex scan is best for DVT as first line investigation and the CTPA for PE.

However when making notes tonight from "Lecture Notes on General Surgery" (11th edition) it seems to suggest a venography for DVT and CXR for first line investigations.

I'm quite certain that for PE a CTPA would be first-line as it's popped up in MCQs and always the right answer but I'm still confused as to what the definitive investigations are. Can anybody help me out with this or perhaps point me in the right direction e.g. official guidelines or something?

Thanks.
It Depends upon the assessed risk of having a DVT

http://eng.mapofmedicine.com/evidenc...nagement1.html
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Sadalsuud
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Check this out, It might help you:

http://www.guideline.gov/algorithm/5885/NGC-5885_1.pdf

http://www.guideline.gov/algorithm/7231/NGC-7231_2.pdf

You can find these in google using DVT & PE algorithm as key words, I hope it is useful. Good luck!
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randdom
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(Original post by carcinoma)
It Depends upon the assessed risk of having a DVT

http://eng.mapofmedicine.com/evidenc...nagement1.html
That is basically what we did for DVTs when I was on AMU. We calculated the wells score and then depending on whether they were clinically high or low risk did either a d-dimer or a doppler.

For PE again it was a clinical assessment with a different wells score and if it was considered likely we did a CTPA, however they would have normally had a chest x-ray, bloods and ecg before that to look into other potential causes of breathlessness. If the patient was a pregnant woman our protocol said to do bilateral leg doppler though I didn't ever have to do that)
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carcinoma
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(Original post by randdom)
That is basically what we did for DVTs when I was on AMU. We calculated the wells score and then depending on whether they were clinically high or low risk did either a d-dimer or a doppler.

For PE again it was a clinical assessment with a different wells score and if it was considered likely we did a CTPA, however they would have normally had a chest x-ray, bloods and ecg before that to look into other potential causes of breathlessness. If the patient was a pregnant woman our protocol said to do bilateral leg doppler though I didn't ever have to do that)
Oh Yea, I forgot about PE.

Here is the Map of Medicine for PE too, its pretty much what you have said.

http://eng.mapofmedicine.com/evidenc...nagement2.html
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Daveo
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You won't get a CTPA in most hospitals without having done a CXR first. This is not because CXR is an investigation for PE ( although rarely you can see signs) but because you should rule out other causes of SOB prior to CTPA. Lets not even get into the CTPA / VQ debate
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j00ni
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(Original post by Daveo)
You won't get a CTPA in most hospitals without having done a CXR first. This is not because CXR is an investigation for PE ( although rarely you can see signs) but because you should rule out other causes of SOB prior to CTPA
Yeah, most radiologists would get pretty grumpy having to perform needle thoacostomy in CT scanner for the missed tension pneumo lol
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Warrior King
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Thanks for the replies everyone. It looks like I have settled on Duplex for DVT and CTPA for a PE. With regards to DVT obviously Wells scoring needs to be taken into account and even if based on this DVT isn't likely, we'd then do D-dimer to rule out the possibility.

Thanks.
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