VTE Prevention & Treatment – GCC Nursing Guide

VTE Fundamentals & Risk Factors

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Annual incidence: 1–2 per 1,000 population. VTE (DVT + PE) is the third most common cardiovascular disease globally and a leading cause of preventable hospital mortality.

Virchow's Triad — The Pathophysiological Foundation

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Stasis

Immobility, cardiac failure, long-haul flights (>4h), prolonged bed rest, paralysis, venous obstruction

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Endothelial Injury

Trauma, surgery, IV catheters, sepsis, inflammatory vasculitis, varicose veins, chemical irritants

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Hypercoagulability

Pregnancy, cancer, thrombophilia, OCP/HRT, dehydration, polycythaemia, nephrotic syndrome

DVT — Deep Vein Thrombosis

95% occur in lower limb
Calf (distal) DVT: below-knee veins — lower PE risk, may resolve spontaneously or extend proximally
Proximal DVT: popliteal, femoral, iliac veins — significantly higher risk of PE (~50% asymptomatic PE)
Upper limb DVT (axillo-subclavian) — ~5%, effort-related (Paget-Schroetter) or catheter-related
Thrombus propagation to pulmonary vasculature = PE

PE — Pulmonary Embolism

Thrombus migrates from venous system → right heart → pulmonary artery
Massive PE: haemodynamic instability (SBP <90 mmHg) — mortality up to 30–50%
Submassive PE: right heart strain, normal BP
Subsegmental/small PE: incidental finding, mild symptoms
10% of all in-hospital deaths attributable to PE (WHO)

VTE Risk Factors — Comprehensive Overview

Surgical

Major surgery (highest risk)
Orthopaedic surgery — hip/knee arthroplasty (highest surgical risk category)
Abdominal/pelvic surgery
Neurosurgery
General anaesthesia >30 min

Patient Factors

Immobility >3 days
Age (risk doubles each decade after 40)
Obesity (BMI >30)
Previous VTE
Antipsychotic use

Medical Conditions

Cancer (pancreatic/haem/brain — highest)
Acute MI, heart failure
IBD (Crohn's, UC)
Nephrotic syndrome
Polycythaemia vera

Thrombophilia

Factor V Leiden (most common inherited)
Antiphospholipid syndrome
Protein C/S deficiency
Antithrombin deficiency
Prothrombin gene mutation

Hormonal / Obstetric

Pregnancy — 20× increased risk
Post-partum period (highest first 6 weeks)
OCP (especially 3rd/4th generation)
HRT (combined oestrogen/progestogen)
Tamoxifen/SERM therapy

GCC-Specific Context

High obesity prevalence (GCC region >35% adult obesity)
High surgical volumes (medical tourism)
Cultural/work patterns → prolonged sedentary periods
Hajj/Umrah pilgrims — long-haul flights + mass gathering
High prevalence of diabetes/metabolic syndrome

VTE Risk Assessment Tools

Padua Prediction Score

Medical inpatients. Score ≥4 = high risk → pharmacological prophylaxis indicated. Interactive calculator in Tab 6.

Caprini Risk Assessment

Surgical patients. Assigns weighted risk scores (1–5 per factor). Low (0–1)/Moderate (2)/High (3–4)/Highest (≥5). Guides prophylaxis intensity.

Wells Score

Clinical pre-test probability for DVT or PE. Used alongside D-dimer and imaging to determine diagnostic pathway. Detailed in Tabs 2 & 3.

DVT Recognition & Diagnosis

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Clinical diagnosis is unreliable. Up to 50% of DVTs are clinically silent. Objective testing (D-dimer + duplex USS) is always required to confirm or exclude DVT.

Clinical Features of DVT

Unilateral leg swelling — asymmetry >2 cm at same level = clinically significant
Erythema (redness) and warmth along venous distribution
Tenderness on deep palpation along the vein course
Pitting oedema — unilateral
Dilated superficial collateral veins (Pratt's sign)
Skin discolouration (phlegmasia cerulea dolens — severe)

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Homan's Sign is UNRELIABLE — calf pain on dorsiflexion has poor sensitivity (50%) and specificity. Do NOT use as diagnostic criterion. It is obsolete in clinical practice.

Bilateral vs Unilateral Swelling

Key differentiator in clinical assessment:

Unilateral swelling → think DVT until proven otherwise
Bilateral swelling → more likely systemic cause: cardiac failure, CKD/nephrotic syndrome, hepatic failure, hypoalbuminaemia, venous insufficiency
Both legs DVT → possible IVC thrombosis (rare) — requires CT venography/MRV
Upper limb DVT: arm swelling, neck vein distension, cyanosis of arm

Wells DVT Score — Pre-Test Probability

Clinical Feature	Points
Active cancer (treatment ongoing, within 6 months, or palliative)	+1
Paralysis, paresis, or recent plaster immobilisation of lower extremity	+1
Recently bedridden >3 days, or major surgery within 12 weeks	+1
Localised tenderness along distribution of deep venous system	+1
Entire leg swollen	+1
Calf swelling >3 cm compared with asymptomatic leg	+1
Pitting oedema (greater in symptomatic leg)	+1
Collateral superficial veins (non-varicose)	+1
Previously documented DVT	+1
Alternative diagnosis at least as likely as DVT	−2

Score ≤1

Low probability — D-dimer: if normal → DVT excluded

Score = 2

Moderate probability — D-dimer + USS if positive

Score ≥3

High probability — proceed directly to USS imaging

D-Dimer

Sensitivity ~95%, specificity 40–60%
A fibrin degradation product — elevated by ANY clot (also surgery, infection, cancer, pregnancy)
Normal D-dimer + low/moderate Wells = DVT excluded (high negative predictive value)
Elevated D-dimer with any Wells score → requires duplex USS
Age-adjusted D-dimer threshold: age × 10 µg/L in patients >50 years (increases specificity)
Not useful in high pre-test probability — proceed directly to imaging

Duplex Ultrasound (USS)

Gold standard for DVT diagnosis
Non-invasive, no radiation, widely available in GCC
Compressibility test: non-compressible vein = DVT (thrombus prevents wall collapse)
Colour Doppler flow: absent or reduced flow in thrombosed segment
Above-knee vs below-knee DVT management differs (see Tab 4)
Sensitivity ~95% for proximal DVT; ~75% for isolated calf DVT
Bilateral whole-leg USS if pelvic/IVC thrombosis suspected

Special DVT Scenarios

Paget-Schroetter Syndrome

Effort-induced axillo-subclavian vein thrombosis. Young athletes (swimmers, baseball). Thoracic outlet syndrome underlying cause. Presents with dominant arm swelling, pain, venous engorgement.

Catheter-Related DVT

Central venous catheter / PICC line — leading cause of upper limb DVT in hospitalised patients. Risk: tip position, catheter size, left-sided placement. Requires anticoagulation + consider catheter removal.

IVC / Pelvic Vein Thrombosis

Bilateral leg swelling + back pain. USS unable to visualise iliac veins / IVC adequately. Requires CT venography or MR venography (MRV). Often presents post-partum or with pelvic malignancy.

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Nursing Action: Any patient presenting with unilateral leg swelling, warmth, or tenderness should be assessed using Wells score immediately. Document findings, escalate promptly, apply Wells scoring, and do not delay anticoagulation if PE symptoms co-exist.

PE Recognition & Diagnosis

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MASSIVE PE = HAEMODYNAMIC EMERGENCY. SBP <90 mmHg or drop >40 mmHg for >15 min not due to other cause. Immediate resuscitation, CTPA if feasible, systemic thrombolysis if confirmed or highly suspected.

PE Clinical Spectrum — ESC Classification

🔴 Massive PE (High Risk)

Haemodynamic instability
SBP <90 mmHg, shock
Cardiac arrest
Mortality: 30–50%
→ Thrombolysis/embolectomy

🟡 Submassive PE (Int. Risk)

Haemodynamically stable
RV dysfunction on echo/CT
Elevated Troponin/BNP
Mortality: 3–15%
→ Anticoagulation ± rescue thrombolysis

🟢 Low-Risk PE

Haemodynamically stable
No RV dysfunction
Normal biomarkers
Mortality: <1–3%
→ Anticoagulation, consider outpatient

PE Symptoms & Signs

Dyspnoea — most common (73%), often sudden onset
Pleuritic chest pain — sharp, worse on inspiration (peripheral PE → infarction)
Haemoptysis — blood-stained sputum (pulmonary infarction)
Syncope/presyncope — massive PE, reduced cardiac output
Cough (dry or productive)

Leg symptoms (DVT co-existing — ~40%)
Tachycardia (most common sign) — HR >100 bpm
Tachypnoea >20 breaths/min
Low SpO₂ / hypoxaemia
Loud P2 (pulmonary hypertension), parasternal heave
Low-grade fever (inflammation)

Wells PE Score — Pre-Test Probability

Clinical Feature	Points
Clinical signs and symptoms of DVT	+3
PE is the #1 diagnosis OR equally likely as alternative	+3
Heart rate >100 bpm	+1.5
Immobilisation >3 consecutive days OR surgery within 4 weeks	+1.5
Previous DVT or PE	+1.5
Haemoptysis	+1
Malignancy (active treatment, treated in last 6 months, or palliative)	+1

≤4 — Low/Unlikely

Use PERC rule → if all criteria met: exclude PE. If not: D-dimer

4.1–6 — Moderate

D-dimer. If elevated → CTPA

>6 — High

Proceed directly to CTPA. Start anticoagulation immediately

PERC Rule (Pulmonary Embolism Rule-out Criteria)

Apply only if Wells PE ≤4 AND clinician's gestalt is "low probability". ALL 8 must be true to rule out PE without D-dimer:

Age <50 years
Heart rate <100 bpm
SpO₂ ≥95% on room air
No unilateral leg swelling
No haemoptysis
No oestrogen use (OCP/HRT)
No prior DVT or PE
No recent surgery or trauma requiring hospitalisation within 4 weeks

If ALL met → PE excluded. No further testing needed.

Investigations for PE

CTPA — CT Pulmonary Angiography: gold standard. Rapid, widely available, concurrent diagnosis of alternative conditions. Preferred in most haemodynamically stable patients
V/Q Scan — Ventilation/Perfusion scintigraphy: preferred if CTPA contraindicated (CKD, contrast allergy, pregnancy — lower radiation to foetus)
D-Dimer — high sensitivity (95%), used in low/moderate pre-test probability
Echocardiography (TTE/TOE) — RV dilatation, McConnell's sign, RV:LV ratio >0.9, bowing of septum, direct thrombus visualisation
Troponin I/T — elevated = myocardial injury from RV strain, prognostic marker
BNP/NT-proBNP — elevated = RV pressure overload, poor prognosis

ECG Findings in PE

Sinus tachycardia — most common finding (>40%)
S1Q3T3 — classic but seen in <20%: S wave lead I, Q wave lead III, T-wave inversion lead III
Right bundle branch block (RBBB) — complete or incomplete

T-wave inversions V1–V4 (right ventricular strain pattern)
Right axis deviation (RAD)
P pulmonale (peaked P waves lead II)
New AF or atrial flutter (less common)

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Normal ECG does NOT exclude PE. ECG findings are non-specific. Their value is to support clinical suspicion and guide further workup.

VTE Treatment

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Treatment goals: prevent clot propagation, prevent PE, enable clot resolution, prevent recurrence, and avoid post-thrombotic syndrome (PTS) in DVT.

Anticoagulation — First-Line Treatment

Rivaroxaban (Xarelto®) — DOAC, Factor Xa Inhibitor FIRST LINE DVT/PE

DVT/PE Dose15 mg BD × 21 days → 20 mg OD with evening meal (ongoing)

MonitoringNo routine INR monitoring needed

Key TrialsEINSTEIN-DVT, EINSTEIN-PE trials

ContraindicationsPregnancy, severe CKD (CrCl <15), antiphospholipid syndrome (triple positive)

Reversal AgentAndexanet alfa (AndeXXa®)

Apixaban (Eliquis®) — DOAC, Factor Xa Inhibitor FIRST LINE DVT/PE

DVT/PE Dose10 mg BD × 7 days → 5 mg BD (ongoing)

MonitoringNo routine INR monitoring

Key TrialsAMPLIFY trial

AdvantageLowest GI bleeding risk among DOACs, renal clearance ~27% (safer in moderate CKD)

Reversal AgentAndexanet alfa (AndeXXa®)

Edoxaban (Lixiana®) / Dabigatran (Pradaxa®) REQUIRES INITIAL LMWH

Edoxaban Dose60 mg OD (after ≥5–10 days LMWH)

Dabigatran Dose150 mg BD (after ≥5–10 days LMWH) — RE-COVER trial

Dabigatran ReversalIdarucizumab (Praxbind®)

CautionDabigatran: CrCl <30 contraindicated; dyspepsia common; P-gp interactions

LMWH — Low Molecular Weight Heparin (Enoxaparin/Tinzaparin/Dalteparin) CANCER / PREGNANCY / BRIDGE

Enoxaparin Treatment Dose1 mg/kg SC BD or 1.5 mg/kg SC OD

Cancer-Associated VTELMWH preferred (Dalteparin — CLOT trial); DOACs increasingly accepted (CARAVAGGIO trial — apixaban)

PregnancyLMWH ONLY — DOACs cross placenta (contraindicated). Weight-adjusted, anti-Xa monitoring if indicated

Reversal AgentProtamine sulfate (partial reversal)

Renal AdjustmentReduce/switch to UFH if CrCl <30 mL/min

Warfarin — Vitamin K Antagonist ANTIPHOSPHOLIPID / MECHANICAL VALVES

Target INR2–3 for most VTE; 3–4 for antiphospholipid syndrome (triple positive)

BridgingLMWH bridge until INR therapeutic for 2 consecutive days

InteractionsNumerous drug/food interactions (Vitamin K foods: leafy greens)

ReversalVitamin K IV/oral, Fresh Frozen Plasma (FFP), 4-factor PCC (Beriplex®)

Massive PE Treatment — Emergency Protocol

Immediate: Resuscitation

ABC approach, high-flow O₂, IV access, fluid resuscitation (cautious — RV sensitive to volume overload), vasopressors (noradrenaline), cardiac monitoring

Systemic Thrombolysis (First Choice)

Alteplase (tPA): 10 mg IV bolus + 90 mg over 2 hours. Contraindications: recent surgery/stroke within 3 months, active bleeding, intracranial neoplasm

Catheter-Directed Thrombolysis (CDT)

If systemic thrombolysis contraindicated or failed. Lower dose thrombolytic delivered directly to clot via catheter. Less systemic bleeding risk

Surgical Embolectomy

Cardiothoracic surgery. If thrombolysis contraindicated AND haemodynamically unstable. High surgical mortality but may be only option

ECMO (Extracorporeal Membrane Oxygenation)

Bridge to definitive therapy in refractory cardiac arrest or cardiogenic shock. Available in specialised GCC centres (major university hospitals)

Duration of Anticoagulation

Scenario	Duration
Provoked DVT/PE (transient risk factor)	3 months
Unprovoked first DVT/PE (low bleed risk)	6–12 months then reassess
Recurrent unprovoked VTE	Indefinite
Cancer-associated VTE	Ongoing (while cancer active)
Antiphospholipid syndrome	Indefinite (warfarin)
Isolated calf DVT (high bleed risk)	Surveillance USS OR 3 months

IVC Filter — Inferior Vena Cava Filter

Indication: absolute contraindication to anticoagulation (active major haemorrhage, recent intracranial surgery/haemorrhage) in patients with confirmed DVT/PE
Retrievable filters preferred — remove once anticoagulation possible
Does NOT treat DVT — prevents PE only
Complications: filter migration, IVC thrombosis, filter fracture, post-thrombotic syndrome
Anticoagulation should be restarted as soon as safely possible even with filter in situ

VTE Prophylaxis — Nursing Practice

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NICE NG89 & VTE Prevention Bundle: ALL hospital inpatients must be assessed for VTE risk on admission, documented using validated tool, and reassessed weekly or on any significant clinical change. This is a mandatory CBAHI/JCI quality indicator in GCC hospitals.

Hospital VTE Assessment Process

Assess VTE risk — on admission using validated tool (Padua for medical; Caprini for surgical)
Assess bleeding risk — concurrent; if high bleeding risk → mechanical prophylaxis only
Document assessment — in electronic/paper VTE assessment form (mandatory in GCC hospitals)
Prescribe/initiate prophylaxis — pharmacological and/or mechanical as per risk assessment and prescriber order
Patient/family education — explain VTE risk, importance of prophylaxis, early mobilisation
Reassess weekly or with clinical deterioration/surgery/change in mobility
Reassess on discharge — extended prophylaxis for high-risk patients (orthopaedic surgery)

Pharmacological Prophylaxis (LMWH)

Enoxaparin — Standard Prophylaxis Dose

Standard Dose40 mg SC once daily

High BMI (>100 kg)40 mg BD (or weight-based; check local protocol)

Renal ImpairmentCrCl 15–30: 20 mg OD; CrCl <15: UFH preferred (seek guidance)

Timing Post-Surgery6–12 hours post-op. With neuraxial anaesthesia: 12h before/4h after removal

Inject into anterolateral or posterolateral abdominal wall (alternate sides)
Do NOT expel air bubble from pre-filled syringe
Do NOT rub injection site post-injection
Monitor platelet count (HIT risk — though lower with LMWH vs UFH)
Check CrCl before each new course

Surgical Timing Guidance

Situation	Timing
General surgery	6–12h post-op
Hip/knee arthroplasty	6–12h post-op (extended 35 days hip / 14 days knee)
Spinal/neuraxial anaesthesia — LMWH before	Last dose ≥12h before
Spinal/neuraxial — after catheter removal	Wait ≥4h after removal
Next dose after catheter removal	Wait ≥4h (LMWH)

Mechanical Prophylaxis

TED / Anti-Embolism Stockings (AES)

Provide graduated compression: 18 mmHg ankle → 8 mmHg thigh
Measure correctly:
- Calf circumference: >18 cm and <32 cm → knee length
- Thigh circumference: if >32 cm → thigh length required
- Ankle circumference + lower leg length determine size
Remove at least once daily for hygiene and skin inspection
Check for skin breakdown, pressure sores, tourniquet effect (rolls)
Wrinkled stockings = incorrect application → pressure injury risk

Pneumatic Compression Devices (PCD/SCD)

Sequential Compression Devices — inflate/deflate calf and thigh intermittently
Augment venous return + stimulate fibrinolysis
Particularly important when pharmacological prophylaxis contraindicated (active bleeding, high bleed risk)
Only operate when patient is in bed (disconnect for ambulation)
Ensure device and tubing connected correctly; check alarm function

Contraindications (both TED and PCD):

Peripheral arterial disease (ABPI <0.8)
Suspected DVT in that limb (compression worsens/embolises)
Peripheral neuropathy with sensory loss
Open wounds, skin breakdown, severe oedema, local infection
Acute dermatitis or gangrene

Patient Education — VTE Prevention

Early mobilisation — first post-op day ambulation is gold-standard VTE prevention; sitting at bedside not sufficient
Leg exercises — ankle pumps 10× each hour while in bed (dorsiflexion/plantarflexion); calf raises
Adequate hydration — dehydration causes haemoconcentration, increasing clotting risk; target urine output ≥0.5 mL/kg/h
Avoid prolonged sitting/standing — economy class syndrome: move every 1–2 hours on flights; walk aisle

Report warning signs immediately: unilateral leg swelling/pain/warmth; sudden breathlessness; pleuritic chest pain; haemoptysis; syncope
Post-discharge TED compliance — explain duration, how to apply, daily removal for skin check
LMWH self-injection teaching — site rotation, technique, sharps disposal, missed dose instructions
DOAC counselling — take at same time daily; do not stop without medical advice; report bleeding

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Extended Prophylaxis (NICE Guidance): Total hip arthroplasty — 35 days pharmacological prophylaxis post-op. Total knee arthroplasty — 14 days. Hip fracture surgery — 35 days. Abdominal/pelvic cancer surgery — 28 days. Ensure patients are discharged with supply and education for home injections.

GCC Context, Exam Prep & Padua Score Tool

VTE in the GCC Healthcare Context

CBAHI & JCI — VTE prevention bundle is a mandatory quality indicator in all accredited GCC hospitals
DHA (Dubai), DOH (Abu Dhabi), MOH (KSA/Qatar) — VTE assessment tools embedded in electronic medical records (EMR)
SCFHS — VTE prevention and anticoagulation management in the NCLEX-style Saudi nursing licensing exam
High-risk GCC populations:
- Post-bariatric surgery (very high prevalence in GCC — obesity rates >35%)
- Post-orthopaedic surgery (growing elective surgical volumes)
- Cancer patients (increasing incidence)
- Diabetes/metabolic syndrome (vascular endothelial damage)
Hajj/Umrah VTE: long-haul flights + mass gathering + dehydration + prolonged standing/immobility → very high VTE risk. GCC health authorities recommend LMWH for high-risk pilgrims (previous VTE, immobility, cancer)

Key Exam Points (DHA/DOH/SCFHS/Prometric)

DOACs are first-line for most DVT/PE (not warfarin, not LMWH)
LMWH is first-line in pregnancy (DOACs cross placenta = contraindicated)
LMWH preferred in cancer-associated VTE (though apixaban/edoxaban now accepted)
Homan's sign = unreliable — do not use clinically
Padua score ≥4 = high risk medical patient → pharmacological prophylaxis
Wells DVT ≤1 + normal D-dimer = DVT excluded (no USS needed)
TED stockings contraindicated with ABPI <0.8 (peripheral arterial disease)
Massive PE + haemodynamic instability = systemic thrombolysis (alteplase)
IVC filter used when anticoagulation is absolutely contraindicated
Extended prophylaxis: 35 days hip arthroplasty, 14 days knee arthroplasty
Antiphospholipid syndrome → warfarin (not DOAC in triple-positive)

Practice MCQs — VTE

Click an option to reveal the correct answer and explanation.

Q1. A 65-year-old post-op day 1 hip replacement patient. What is the MOST important immediate nursing intervention for VTE prevention?

A. Apply thigh-length TED stockings only
B. Administer prescribed LMWH and encourage early ambulation
C. Perform passive leg exercises in bed only
D. Elevate both legs above heart level

Both pharmacological (LMWH enoxaparin 40 mg SC) and early ambulation are the cornerstones of post-arthroplasty VTE prevention. Extended prophylaxis continues for 35 days post hip replacement per NICE guidelines.

Q2. A patient's D-dimer result is normal. Their Wells DVT score is 1. What is the CORRECT management?

A. Proceed to duplex USS immediately
B. DVT is effectively excluded — no further imaging needed
C. Start empirical LMWH and arrange outpatient USS
D. Repeat D-dimer in 24 hours

Low pre-test probability (Wells DVT ≤1) combined with a normal D-dimer has a very high negative predictive value (>99%) and effectively excludes DVT. No imaging is required in this scenario.

Q3. Which anticoagulant is CONTRAINDICATED for VTE treatment in pregnancy?

A. Enoxaparin (LMWH)
B. Unfractionated heparin (UFH)
C. Rivaroxaban (DOAC)
D. Tinzaparin (LMWH)

DOACs (rivaroxaban, apixaban, edoxaban, dabigatran) cross the placenta and are teratogenic — absolutely contraindicated in pregnancy. LMWH is the treatment of choice as it does NOT cross the placenta. Warfarin is also contraindicated in first trimester (teratogenic) and near term (fetal haemorrhage).

Q4. A patient with Wells PE score of 7 presents with dyspnoea and tachycardia. Blood pressure is 110/70 mmHg. What is the PRIORITY diagnostic test?

A. D-dimer blood test
B. ECG only
C. CT Pulmonary Angiography (CTPA)
D. Chest X-ray and ABG

Wells PE score >6 = high pre-test probability. D-dimer is NOT indicated at this probability level — proceed directly to CTPA (gold standard). Anticoagulation should be started immediately while awaiting imaging if no contraindications. D-dimer has poor specificity and would not change management in high pre-test probability.

Q5. A patient has a Padua Prediction Score of 5. What is the MOST appropriate action?

A. TED stockings alone — no pharmacological prophylaxis needed
B. No prophylaxis required — score is too low
C. Assess bleeding risk, then initiate LMWH (enoxaparin 40 mg SC OD) if no contraindication
D. Start oral rivaroxaban immediately

Padua score ≥4 = high risk → pharmacological prophylaxis indicated (LMWH enoxaparin 40 mg SC OD) provided bleeding risk assessment is favourable. Always assess bleeding risk concurrently. Rivaroxaban is not used for prophylaxis in medical inpatients at standard dosing without specific indication.

Q6. Which finding is a CONTRAINDICATION to applying TED anti-embolism stockings?

A. Post-operative day 1 following knee replacement
B. ABPI of 0.7 (peripheral arterial disease)
C. BMI of 32
D. History of previous DVT (5 years ago)

TED stockings are contraindicated when ABPI <0.8, indicating significant peripheral arterial disease. Applying compression would further reduce arterial perfusion and cause ischaemic injury. Other contraindications: suspected DVT in that limb, severe peripheral neuropathy, open wounds, acute dermatitis, severe oedema distorting limb shape.

Q7. A patient presents with massive PE in haemodynamic shock (SBP 75 mmHg). CTPA confirms massive bilateral PE. What is the FIRST-LINE definitive treatment?

A. Start rivaroxaban oral anticoagulation immediately
B. Urgent IVC filter insertion
C. Systemic thrombolysis — alteplase 10 mg IV bolus + 90 mg over 2 hours
D. LMWH enoxaparin at treatment dose SC

Massive PE with haemodynamic instability and no contraindications = systemic thrombolysis (alteplase). Oral anticoagulants are inadequate for acute massive PE as they have no immediate effect on existing clot. LMWH SC has unreliable absorption in shock. IVC filter does not treat existing PE — it prevents further emboli only.

Q8. A 28-year-old female at 18 weeks gestation develops confirmed proximal DVT. Which anticoagulation regimen is MOST appropriate?

A. Weight-adjusted LMWH (e.g. enoxaparin 1 mg/kg SC BD) throughout pregnancy and 6 weeks post-partum
B. Apixaban 10 mg BD for 7 days then 5 mg BD
C. Warfarin INR 2–3 throughout pregnancy
D. Aspirin 75 mg OD as sole treatment

LMWH is the standard treatment for VTE in pregnancy — does not cross the placenta, safe for foetus. DOACs are absolutely contraindicated (teratogenic, foetal haemorrhage risk). Warfarin crosses the placenta — causes embryopathy in first trimester (weeks 6–12) and foetal/neonatal haemorrhage near term. Aspirin alone is inadequate for treatment of established DVT.

Q9. Which condition has the HIGHEST risk of cancer-associated VTE?

A. Well-differentiated thyroid carcinoma
B. Basal cell carcinoma of skin
C. Pancreatic adenocarcinoma
D. Localised prostate cancer

Pancreatic cancer carries the highest VTE risk among solid tumours (~20% cumulative incidence). Other high-risk cancers: brain tumours (glioblastoma), haematological malignancies (lymphoma, myeloma), gastric cancer, lung cancer. VTE is the second leading cause of death in cancer patients after the malignancy itself (Trousseau's syndrome).

Q10. For a patient on warfarin for VTE with an INR of 5.8 and no active bleeding, what is the CORRECT immediate nursing action?

A. Administer Vitamin K 10 mg IV urgently
B. Continue warfarin at same dose and recheck in 1 week
C. Withhold warfarin, notify prescriber, monitor closely for bleeding signs
D. Administer FFP immediately to reverse anticoagulation

INR 5–9 without bleeding: hold warfarin, notify prescriber. Prescriber may consider low-dose oral Vitamin K (1–2.5 mg) to bring INR down. Recheck INR in 24–48h. FFP/PCC is reserved for major/life-threatening bleeding or emergency reversal. High-dose IV Vitamin K may over-correct causing thrombosis. Always follow local institutional protocol and document clearly.

Venous Thromboembolism (VTE)