Skip to content
Call Book
Pulmonary

VTE diagnostics

Pretest probability first: Wells (outpatient), Geneva, PERC (rule-out), YEARS/PEGeD for pregnancy and probability-adjusted D-dimer.

Alberto M. Sobrero5 min6 questions5 trials

The bedside picture

DVT

  • Pain, warmth, asymmetric edema, cord. Homan’s sign is neither sensitive nor specific.
  • Proximal = iliac / femoral / popliteal. Distal = calf veins.
  • Phlegmasia cerulea dolens is a vascular emergency — thrombolyse.
  • May-Thurner: R iliac artery crushes L common iliac vein → left leg swelling.
  • Upper-extremity DVT: PICC > centrally inserted > ports ().

PE

  • Dyspnea, pleuritic pain, cough, syncope, hemoptysis — or nothing.
  • Exam: tachypnea, tachycardia, hypoxemia, loud P2, RV heave, JVD.
  • ECG: sinus tach first. Then AF, RBBB, T-wave inversions, S1Q3T3 ().
  • Risk follows Virchow: stasis, injury, hypercoagulability (:I-9; ESC 2019 / ERJ 2020).
Risk tierExamples
StrongHospitalized HF/AF within 3 months, MI, hip/knee replacement, limb fracture, major surgery/trauma, spinal cord injury
ModerateThrombophilia, prior VTE, knee arthroscopy, CVC, estrogen, pregnancy/postpartum, IVF, cancer, chemotherapy, HIV, IBD, nephrotic syndrome, infection
WeakBed rest >3 days, long travel, age, obesity, laparoscopic surgery, antepartum pregnancy

Choose a test on purpose

Pretest probability decides the pathway

  • Low

    YEARS / PERC / age-adjusted D-dimer

    A negative high-sensitivity D-dimer can stop the workup (Christopher; ). PERC-negative ED patients do not need a dimer.

  • Intermediate

    D-dimer, then CTPA or V/Q

    CTPA is first-line if kidneys and contrast allow. V/Q if contrast-allergic, pregnant (after CXR), or to follow chronic PE.

  • High / shock

    Do not wait on a dimer

    CTPA if stable enough. Bedside echo for RV strain if crashing. Treat empirically when the delay is dangerous.

taught us V/Q is a likelihood ratio, not a yes/no. Combine it with pretest probability.

  • LE ultrasound: first test for DVT; a positive proximal study can spare CTPA if you were going to anticoagulate anyway.
  • Do not order a dimer after a week of hospitalization — it will be positive and useless.