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Diagnosing venous thromboembolism – protocols and problems, the

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Diagnosing venous thromboembolism – protocols and problems, the Powered By Docstoc
					Diagnosing venous thromboembolism
– protocols and problems,
the Salford experience

                       Kerstin Hogg
                     Clinical Lecturer,
                 University of Manchester
Problems with diagnosing PE

   Paradigm shift in approach to diagnosis with
    Wells, Canada, 1998

   Structured clinical probability scoring
   Dislike for D-dimer
   Evolution of CT scanning
Problems with diagnosing DVT

    Doctors cannot diagnose DVT by looking at a leg

    Structured clinical probability scoring
    Dislike for D-dimer
    Many hospitals only scan the thigh
    Lack of consistent approach to
1.   Below knee DVTs
2.   Chronic thrombosis
Approach in Salford Royal Hospital

Emergency Department centralised DVT service

Hospital working group

Hospital wide electronic protocols

Education, education, education
Population

   929 approached for the study
   448 consented and investigated for DVT
   358 consented and investigated for PE
   98 lacked capacity
   25 declined to participate
Demographics

   60% female
   mean age 60
   13% inpatients
   14% had had a recent hospital admission
   6% post-op orthopaedics
   14% anticoagulated
   18% past history VTE
   10% cancer
   2% pregnant
   4% IVDAs
                       448 investigated for DVT




98 low / moderate Wells score
                                    350 patients had USS ordered
     and negative D-dimer



                  69 had DVT diagnosed on
                       first thigh USS

                                                  28 failed to have two USS
                  16 had DVT diagnosed on
                      second thigh USS




          No DVTs or PE diagnosed during three month follow up
DVT PROBLEMS


   Recognising a chronic DVT
   IVDAs
   Below knee DVTs
                  358 investigated for PE




 76 low Wells score
                               282 patients had imaging ordered
and negative D-dimer


                18 had VQ scanning



                   254 had CTPA
                                            12 failed to have imaging


           62 patients diagnosed with PE



       Two patients with a negative CTPA were diagnosed
             with PE during the 3 month follow up
PE PROBLEMS


   2 false negative CTPAs
   Lack of use Wells score/D-dimer
   Differentiating acute from chronic PE
Questions?

				
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posted:6/24/2012
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