Venous Thromboembolism (VTE): A Practical Guide for Resident Doctors

Venous Thromboembolism (VTE) is a collective term for deep vein thrombosis (DVT) and pulmonary embolism (PE). It’s common, potentially fatal, and often missed — especially in the ED hustle.

In this post, I’ll walk you through how to think, ask, examine, test, and treat VTE using a junior-doctor-friendly approach backed by Oxford Handbook of Emergency Medicine, WikEM, BMJ Best Practice, NICE,GPnotebook, and RCEM Learning.

History-Taking: What to Ask

Suspected DVT

·     Where is the leg pain/swelling? Onset? One or both legs?

·     Any recent immobilization or travel? (>4 hours, e.g., long-haul flight)

·     Surgery or trauma in past 8 weeks?

·     Active cancer or treatment in past 6 months?

·     Previous DVT/PE?

·     OCP or HRT use?

·     Pregnancy or postpartum?

·     Any family history of clotting disorders?

·     Systemic symptoms? Fever (could suggest infective cause), weight loss (think cancer).

Suspected PE

·     Chest pain — is it pleuritic (sharp, worse on inspiration)?

·     Shortness of breath — onset, exertional or at rest?

·     Cough or haemoptysis?

·     Palpitations or syncope?

·     Leg symptoms? (e.g., DVT signs in history)

·     Recent travel, surgery, or bed rest?

·     Cancer, pregnancy, hormone use?

Examination: What to Look For

Suspected DVT

·     Unilateral leg swelling (compare calf circumference)

·     Tenderness along the deep veins (especially calf)

·     Pitting oedema

·     Erythema, warmth

·     Dilated superficial veins

·     Homan’s sign (not reliable)

Suspected PE

·     Tachypnoea, tachycardia

·     Hypoxia or low O2 sat

·     Raised JVP or hypotension (massive PE)

·     Pleural rub or crepitations

·     Signs of right heart strain: loud P2, parasternal heave

·     Signs of DVT (in the legs)

Investigations: What to Order

Risk Stratify First

Use clinical scoring tools:

Suspected Condition	Score
DVT	Wells Score
PE	Wells Score / PERC rule / Geneva Score

Suspected DVT

·     Wells Score ≥2: DVT likely → Do proximal leg vein ultrasound<2: DVT unlikely → Do D-dimer

·     If D-dimer +ve → UltrasoundIf D-dimer –ve → DVT ruled out

·     D-dimer: High sensitivity, low specificity.

·     Proximal leg vein ultrasound (duplex): First-line imaging.

·     If symptoms are atypical or persist with negative scan, repeat US in 6–8 days.

Suspected PE

·     Wells Score (PE)

·     4 = PE likely → CTPA≤4 = PE unlikely → D-dimer

·     D-dimer: Negative D-dimer rules out PE in low-risk patients.

·     CT pulmonary angiogram (CTPA): Gold standard.

·     V/Q scan: If CTPA contraindicated (e.g., renal impairment, contrast allergy).

·     ECG: Sinus tachycardia is most common. May see S1Q3T3 pattern in massive PE.

·     ABG: May show hypoxia and low PaCO₂.

·     Troponin and BNP: May be elevated in RV strain.

·     Echo: For risk stratification in massive/submassive PE (look for RV dilation).

Management: Step-by-Step Plan

Initial Stabilisation (especially for PE)

·     ABC approach

·     Oxygen if hypoxic

·     IV access, fluids if hypotensive (but avoid overload in RV failure)

·     Consider thrombolysis if massive PE with haemodynamic instability

Anticoagulation

Start anticoagulation as soon as diagnosis is suspected, unless contraindicated.

Options:

·     Apixaban or Rivaroxaban (DOACs): First-line in most patients

·     LMWH (e.g., enoxaparin) → warfarin bridge: If DOAC not suitable

·     LMWH alone: In cancer-associated thrombosis or pregnancy

·     Unfractionated heparin (UFH): If high bleeding risk or considering thrombolysis

Duration of Treatment:

·     Provoked VTE (e.g., surgery, travel): 3 months

·     Unprovoked VTE: At least 3–6 months, consider lifelong in selected cases

·     Cancer-associated: As long as cancer active

·     Pregnancy: LMWH until 6 weeks postpartum (minimum 3 months)

Thrombolysis (for PE only)

• Indications: Massive PE with hypotension or RV failure

• Agent: Alteplase

• Consider ICU or HDU referral

VT-Specific Notes

·     Compression stockings may reduce risk of post-thrombotic syndrome

·     Advise mobilisation, not bed rest

·     Avoid LMWH in renal failure (CrCl <30) — use UFH instead