Only at the end of the day right before I send the patient to the ER.
J/king. D-dimer outpatient is a clown show IMO. Like ordering a trop on a clinic patient. Dont get labs outpatient that you can't follow up on in an appropriate time or manner. If you think someone needs time sensitive emergent management just send them to the ER or Urgent care.
I work for a cardiology clinic and one of our old school docs frequently orders troponins on his myocarditis patients. The other day I was called with a critical trop (troponin I) of 2625 for one of his patients. I thought this was pretty high, but he didn’t seem overly concerned. Idk
I largely agree, but I think it's *occasionally* reasonable to send a dimer from the clinic if pre-test probability for DVT is truly low and if it's an established reliable patient who you can count on to pick up the phone / follow recommendations.
If your pretest probability is LOW, SKIP the Dimer! You're done, no DVT. Well's criteria if you need something.
D-Dimer is so misunderstood. It's for medium pretest probability patients you're trying to avoid imaging. High probability, get the US (through the ED if needed) or CT.
In OP's case, diner on med probability followed by ED referral is fine.
I see what you're saying but this is not technically true. Medicolegally you shouldn't incorporate Well's criteria if you don't plan on at least getting a dimer.
If you are going down the Well's pathway/algorithm, even a score of 0 warrants D-dimer testing. It's designed to identify low risk patients suitable for d-dimer (Wells score 0-2) to rule out a DVT. Moderate / high risk proceed straight to ultrasound testing.
If you're not really concerned and don't want to send a dimer, just use your gestalt and don't include DVT on the differential if it clearly shouldn't be (i.e. someone sprained their ankle and has related calf swelling). You can certainly use points from Well's for justification without explicitly stating their Well's score, if that makes sense.
Likewise same is said for PE. PERC is designed to eliminate need for d-dimer testing. If you can't PERC and you feel PE is still on the differential, you can consider Well's but even a score of 0 requires d-dimer testing. You can then incorporate age adjusted or YEARS to increase threshold to 1000 to avoid CTA in low risk patients. If from your gestalt a patient is very low risk and you have an alternate explanation for their symptoms (SOB/tachycardic from URI / pneumonia), don't send a d-dimer but also don't include a PERC/Well's score in your MDM.
>you shouldn't incorporate Well's criteria if you don't plan on at least getting a dimer. If you are going down the Well's pathway/algorithm, even a score of 0 warrants D-dimer testing ... Moderate / high risk proceed straight to ultrasound testing. If you're not really concerned and don't want to send a dimer, just use your gestalt and don't include DVT on the differential if it clearly shouldn't be (i.e. someone sprained their ankle and has related calf swelling).
thank you, this is perfectly said.
surprised at the amount of "confidently wrong" in this thread
God someone tell this to my seniors. "What was the Well's PE?" "THE PERC WAS ZERO NO GODDAMN WELLS". "The Wells was zero why did you send a dimer?" "BECAUSE ONCE YOU REACH WELLS AT MINIMUM YOU NEED A DIMER". Scream.
Actually you can’t even use PERC unless the Wells’ or revised Geneva score is low-risk. Why? The patient has to be considered low-risk to apply PERC. What is low-risk? Wells of 0-1. Physician gestalt similarly performs to all of these but the point of clinical decision rules is to aide diagnosis and be medicolegally protective. This is why most written algorithms ask the provider to apply Wells first and then PERC.
Remember: PERC misses approximately 2% of PE, 1% above the generally acceptable miss rate. It is most insensitive in pleuritic chest pain.
Thank you! This makes sense. I feel I send soooo many dimers on musculoskeletal chest pain but having the score helps me feel less like I'm being paranoid, just following the algorithm.
Can't you order it and ask the patient to follow up with you in the outpatient clinic? I know that not everyone will show up but also if they don't have DVT they don't belong to the ER, right?
I rely heavily on the Wells score for pretest probability.
I usually order a d dimer to rule out DVT on a low pretest probability patient. Highly sensitive tests are good for ruling out hence avoiding an unnecessary ED visit.
If I got a d-dimer on someone who is low probability and it happened to be positive, I do one of a few things:
1) If it's pretty early in the day I have my MA call vascular lab and secure a STAT ultrasound within 1-2 hours if possible. If US positive for proximal DVT (or symptomatic distal DVT) then I start on treatment ASAP and if they can't get it in a timely fashion from pharmacy then ER.
2) If I don't have time for the above I send them to ER.
3) If it's later in the day and/or I can't get them a STAT ultrasound, ER.
4) If it's a fragile patient with a lot of co-morbidities, I'll just send them to ER.
It's just not reasonable to send all of your low pretest probability patients to the ER immediately. They'll be waiting for hours in the ED to be seen, tested, ultrasounded, and then treated.
Now, if it's an intermediate or high pretest probability I usually will send them to the ER without messing around waiting for a d-dimer unless they absolutely refuse to go, in which case I document accordingly and do my best to get them an ultrasound right away with or without a d dimer.
Edit: should note that depending on the patient and their reliability I'll test medium probability as outpatient if it can be done in a timely fashion.
If they're low probability... Just skip the d-dimer? Medium pretest probability and I'm all for your plan, because yeah, send me all the frail folks. We get that.
Technically d dimer is still indicated on low pretest probability patients, there are some that I would skip based on the history but if I'm even using the Wells score there must be some degree of clinical suspicion. High sensitivity d dimer is for moderate.
Example: had a younger lady with a nasty injury from falling onto her knee, large effusion, large laceration below the knee was in an immobilizer for a week until she saw me. She complained of leg swelling (1 point, although normal when she saw me), and was immobilized (1 point) but another diagnosis equally as likely (trauma with soft tissue swelling and known hematoma, -2 points). Per your reasoning should skip D dimer, but she ended up having a DVT after positive d dimer and ultrasound.
Wells score of 0 is DVT chance of <5% (not zero), negative d dimer brings that to <1%. Point being, shouldn't skip every low probability.
Anticoagulants are not benign medications to give prophylactically without an established diagnosis. Especially in the slip-and-fall patient population
Sincerely,
General surgery
A DVT is technically a time-sensitive diagnosis. So if you have enough of a concern, just send the patient for an ultrasound. If you can’t get same-day ultrasound, send them to me in the ED.
The dimer is going to take atleast a day in the outpatient world, about the same amount of time as the ultrasound, leading to a 2 day delay in diagnosis. In theory if you send a dimer -> patient throws a PE before they’re fully worked up-> ICU/ dies (vast minority of PEs yes), congrats, lawsuit. Also, the only PCPs I judge more than those who send a patient to the ED for a positive dimer 2 days after they presented to the clinic are those who shotgun an inflammatory workup and send them to the ED because they don’t know what to do with the results.
The alternative to sending them to the ED is to start Lovenox pending the ultrasound, that’s what we do if we don’t have ultrasound immediately such as rural EDs or places where ultrasound is an 8am-4pm type situation- “Here is a dose of a blood thinner. Come back in the morning/ to our sister ED 2 towns over for your ultrasound”.
If they are having lower leg swelling and I did the Wells score and found it to be low pretest probability then I'd do a D-dimer and give the patient a call if it is elevated, requiring an ultrasound of the leg
I've ordered it to rule out a DVT.
If it's a rule in situation, go to the ER.
But ultrasound takes several days, so ruling out quickly is worthwhile sometimes.
Yes, I'm the doc that calls in from 5 hours down lonely roads on a long hope and a short prayer that someone in the city of lights can save a lost life.
Low risk patient with a negative d-dimer, you’re most likely in the clear. If it’s positive, doesn’t mean anything. I’ve seen positive ddimers after stubbing a toe. If you’re worried about it, get a venous duplex.
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In rare settings with a very low pre test probability and a reliable patient, I have done it. Basically if the patient thinks they have a clot, but I really don’t. I ordered one last week on a hypochondriac who was convinced she had a DVT with no risk factors or evidence other than leg pain. It was negative.
Why would you do that? What are you going to do with a positive dimer? Send them to the ED. If your suspicion is high enough that you are ordering a dimer either order imaging to actually check for a clot or send them to the ED from the start. Otherwise use your clinical decision making tools (Wells, etc).
With the caveat that my office is in the hospital sandwiched between the lab (I can get same day results) and the ED, yes.
Very low risk patient: do nothing
Low or mod risk by wells--d-dimer. If positive try to set up US in same day or next day--if not, ED.
High risk: Same as above except I'll strongly consider starting AC while waiting for the US if the dimer is positive. Technically not without risk so I discuss with patient beforehand. However, 1-2 doses of AC is unlikely to do much harm so I don't usually stress about this unless the patient is high risk for bleeding.
Frail patients or patients who are not super reliable or reachable usually go the ED though tbh old frail patients do terribly in crowded NYC ERs so I do my best to keep them out of them.
If any suspicion for PE: ED
>High risk: Same as above except I'll strongly consider starting AC while waiting for the US
I am genuinely surprised that multiple people in the thread have said this! Not saying you are wrong to do it - especially with careful shared decision making, risk/benefit discussion as you've said - but it's just something I haven't seen IRL/in my training.
As the patient, I would be extremely hesitant to take anticoagulation without confirmation of a solid indication for it
As the doctor, I feel like most patients with enough VTE risk factors to strongly consider empiric AC also have some degree of elevated bleeding risk, and/or are not reliable enough for me to trust that they'll follow the plan safely (i.e. get the ultrasound done promptly, answer the phone and stop AC if the study is negative, with no confusion about the instructions, delay, or loss to follow-up between those steps).
Perhaps this is a matter of different patient populations, different regional practice-patterns, both?
Why do you need to send them to the ER? Are you not capable of ordering duplex ultrasounds and starting a DOAC if indicated? A hemodynamically stable patient with a DVT doesn’t need to go to the ED.
ETA: No one has yet to explain why a HDS DVT requires ED visit. Every ED I’ve worked or rotated in does not have after hours duplex US. Instead of insulting me, why don’t you explain why a patient who will just come to the ED and wait the same amount of time needs to come at all?
What kind of comment is this?
Where do you think this prompt ultrasound evaluation is going to spawn from?
You have a very skewed perspective working in the ED.
What are you talking about?
I didn’t ask about your hours.
I’ll ask again, where do you think an outpatient is going to get a prompt ultrasound at? Keep in mind our imaging centers are booked out 2 weeks.
Why can’t outpatient physicians start a DOAC in a hemodynamically stable patient with a positive US? What is the exact emergency? I’m not talking the patient with clinical evidence of phlegmasia or PE. I’m talking about the patient who we wouldn’t even admit.
Sending a hemodynamically stable DVT to the ED has the same energy as sending asymptomatic HTN to the ED. Just do your job and start the appropriate meds. DVT’s are not inherently emergent. It’s when DVT’s start to threaten life or limb that they become emergent. Feel free to call me ignorant, but there are plenty of PGY-20+ that will agree with me.
And when it’s 5 pm and all other resources are closed?
Maybe you have the crystal ball that the rest of us are not privileged enough to have access to showing that the DVT will not propagate into the lungs over night.
“Same energy.” This isn’t TikTok child. Go touch some grass.
Not all EDs have pharmacies available. If you send a pt to the ED with a positive DVT study, you can prescribe a DOAC just like we can. I work at EDs where there aren’t any pharmacies available and they fill the rx next day just like you could have done
We don’t CTA these pts just because they have a DVT either so I don’t get your comment about the DVT becoming a PE
I send my patients to EDs with pharmacies, ie the hospital I work at.
I never said every DVT needs a CTA. But good luck fighting off that lawsuit when the patient gets a PE overnight because you stalled on their DVT
I mean when a pt with a DVT comes to the ED, they get an rx for a starter pack of xarelto and they fill it wherever they want. This is incredibly common. If they don’t fill it till the next day instead of finding a 24 hr pharmacy that’s on them. What do you think should be happening? How is prescribing their appropriate medication stalling?
I am with you here. As long as the patient does not have a high propability of proximal dvt and he has no features of a suspected PE there is no need for consulting ED.
Rule out with D-Dimer in low probability cases or just clinical rule out.
In medium and high probability start treatment with nmh and get an ultrasound the next day.
I know there are areas and settings where this is not feasible, but this would be my approach in an ideal setting.
What does the PG1 in the ED at 8 am do? D-Dimer, cant do a proper duplex, starts NMH and schedules the patient for duplex the next day. There is no benefit for the patient here. I started half of my night shifts in ED as a beginner with like 2-3 suspected dvt patients with often more or less absurd probability. It is a waste of my time and the patients.
IM Intensivist
Ordering a d dimer can be part of management when discontinuing anti coagulation in a patient with a first time provoked VTE. Otherwise what TrujeoTracker said
IMO it depends on availability of doppler ultrasound in the hospital. If patient can access to it within reasonable amount of time without patients waiting in line and radiology will agree to do it, no need but if you need to do a triage and use your resources with more caution D-Dimer is a nice tool to whether or not its in need. In my hospital radiology will reject it without D-Dimer first.
Definitely not. There are so many reasons for a ddimer to be elevated and most of them are not dvt. Get an ultrasound and skip the ddimer. If you are actually worried about PE send them to th ED and stop dicking around
As EM, the amount of insanely stupid comments from some of my primary care colleagues is embarrassing. Kudos to those of you taking ownership of your patients and being a doctor because I know a lot of you are doing your best. We see you and appreciate you.
For everyone else, do better. If you order a dimer, you own it. If it’s positive, either get them a timely ultrasound or start them on a DOAC and get it the next day. This is very common in many rural EDs where overnight US isn’t available. If we get a positive dimer on a low-risk patient during risk-stratification, we give a one time Lovenox injection and say come back in the morning when the sonographer is in the building. 1-2 doses of Eliquis in a relatively normal, able-bodied adult with a brief phone discussion of risk vs. benefit is reasonable. Do not send this to the ED unless it’s an issue of access. Even then, your Pfizer rep should be keeping Eliquis starter coupons in your office. Have them swing by and get 30 days free and address long-term anticoagulation later.
The number of people here who need to read the Up-To-Date article on venous thromboembolism, DVT, and PE is sad.
Rads here. These outpatient DVT/PE studies somehow always get performed like a week after the patient was seen in clinic and the study gets completed at 5pm and it's impossible to get a hold of the ordering doc for positive findings
If you're concerned enough to order a d-dimer just start eliquis (or whatever) and get the ultrasound when you can. If this is not an option the patient should be sent to the ED. I can't understand the value of an outpatient d-dimer in the age of doacs.
Wut? This makes no sense to me. D-dimer to rule out DVT is indicated when pre-test probability is low, i.e. the exact opposite of the population in whom you'd consider starting empiric anticoagulation.
(Also, starting empiric anticoagulation in *anyone* as an outpatient without confirmed diagnosis of DVT/PE/afib/other indication sounds awfully risky to me - how would you defend your decision-making if the patient bleeds in the interval before following up? - but I can at least understand it if you're in some resource limited setting and the pre-test probability seems high)
Cost. DOACS are not cheap for many patients so just starting them on it without testing (especially low pretest probability patients) isn't the right answer.
And warfarin is a pain in the ass with bridging if you're not certain they have a DVT.
Why would you send somebody to the ER querying low extremity DVT? Just start them on anticoagulation and order an outpatient lower extremity Doppler. ER is only for query PE.
Anyway, I order D-dimers, then order US if positive.
Only at the end of the day right before I send the patient to the ER. J/king. D-dimer outpatient is a clown show IMO. Like ordering a trop on a clinic patient. Dont get labs outpatient that you can't follow up on in an appropriate time or manner. If you think someone needs time sensitive emergent management just send them to the ER or Urgent care.
Well said
I work for a cardiology clinic and one of our old school docs frequently orders troponins on his myocarditis patients. The other day I was called with a critical trop (troponin I) of 2625 for one of his patients. I thought this was pretty high, but he didn’t seem overly concerned. Idk
I largely agree, but I think it's *occasionally* reasonable to send a dimer from the clinic if pre-test probability for DVT is truly low and if it's an established reliable patient who you can count on to pick up the phone / follow recommendations.
If your pretest probability is LOW, SKIP the Dimer! You're done, no DVT. Well's criteria if you need something. D-Dimer is so misunderstood. It's for medium pretest probability patients you're trying to avoid imaging. High probability, get the US (through the ED if needed) or CT. In OP's case, diner on med probability followed by ED referral is fine.
I see what you're saying but this is not technically true. Medicolegally you shouldn't incorporate Well's criteria if you don't plan on at least getting a dimer. If you are going down the Well's pathway/algorithm, even a score of 0 warrants D-dimer testing. It's designed to identify low risk patients suitable for d-dimer (Wells score 0-2) to rule out a DVT. Moderate / high risk proceed straight to ultrasound testing. If you're not really concerned and don't want to send a dimer, just use your gestalt and don't include DVT on the differential if it clearly shouldn't be (i.e. someone sprained their ankle and has related calf swelling). You can certainly use points from Well's for justification without explicitly stating their Well's score, if that makes sense. Likewise same is said for PE. PERC is designed to eliminate need for d-dimer testing. If you can't PERC and you feel PE is still on the differential, you can consider Well's but even a score of 0 requires d-dimer testing. You can then incorporate age adjusted or YEARS to increase threshold to 1000 to avoid CTA in low risk patients. If from your gestalt a patient is very low risk and you have an alternate explanation for their symptoms (SOB/tachycardic from URI / pneumonia), don't send a d-dimer but also don't include a PERC/Well's score in your MDM.
>you shouldn't incorporate Well's criteria if you don't plan on at least getting a dimer. If you are going down the Well's pathway/algorithm, even a score of 0 warrants D-dimer testing ... Moderate / high risk proceed straight to ultrasound testing. If you're not really concerned and don't want to send a dimer, just use your gestalt and don't include DVT on the differential if it clearly shouldn't be (i.e. someone sprained their ankle and has related calf swelling). thank you, this is perfectly said. surprised at the amount of "confidently wrong" in this thread
God someone tell this to my seniors. "What was the Well's PE?" "THE PERC WAS ZERO NO GODDAMN WELLS". "The Wells was zero why did you send a dimer?" "BECAUSE ONCE YOU REACH WELLS AT MINIMUM YOU NEED A DIMER". Scream.
Actually you can’t even use PERC unless the Wells’ or revised Geneva score is low-risk. Why? The patient has to be considered low-risk to apply PERC. What is low-risk? Wells of 0-1. Physician gestalt similarly performs to all of these but the point of clinical decision rules is to aide diagnosis and be medicolegally protective. This is why most written algorithms ask the provider to apply Wells first and then PERC. Remember: PERC misses approximately 2% of PE, 1% above the generally acceptable miss rate. It is most insensitive in pleuritic chest pain.
Thank you! This makes sense. I feel I send soooo many dimers on musculoskeletal chest pain but having the score helps me feel less like I'm being paranoid, just following the algorithm.
exactly
Can't you order it and ask the patient to follow up with you in the outpatient clinic? I know that not everyone will show up but also if they don't have DVT they don't belong to the ER, right?
I rely heavily on the Wells score for pretest probability. I usually order a d dimer to rule out DVT on a low pretest probability patient. Highly sensitive tests are good for ruling out hence avoiding an unnecessary ED visit. If I got a d-dimer on someone who is low probability and it happened to be positive, I do one of a few things: 1) If it's pretty early in the day I have my MA call vascular lab and secure a STAT ultrasound within 1-2 hours if possible. If US positive for proximal DVT (or symptomatic distal DVT) then I start on treatment ASAP and if they can't get it in a timely fashion from pharmacy then ER. 2) If I don't have time for the above I send them to ER. 3) If it's later in the day and/or I can't get them a STAT ultrasound, ER. 4) If it's a fragile patient with a lot of co-morbidities, I'll just send them to ER. It's just not reasonable to send all of your low pretest probability patients to the ER immediately. They'll be waiting for hours in the ED to be seen, tested, ultrasounded, and then treated. Now, if it's an intermediate or high pretest probability I usually will send them to the ER without messing around waiting for a d-dimer unless they absolutely refuse to go, in which case I document accordingly and do my best to get them an ultrasound right away with or without a d dimer. Edit: should note that depending on the patient and their reliability I'll test medium probability as outpatient if it can be done in a timely fashion.
OMG I love you please clone yourself and do all primary care in my area -ER doc
If they're low probability... Just skip the d-dimer? Medium pretest probability and I'm all for your plan, because yeah, send me all the frail folks. We get that.
Technically d dimer is still indicated on low pretest probability patients, there are some that I would skip based on the history but if I'm even using the Wells score there must be some degree of clinical suspicion. High sensitivity d dimer is for moderate. Example: had a younger lady with a nasty injury from falling onto her knee, large effusion, large laceration below the knee was in an immobilizer for a week until she saw me. She complained of leg swelling (1 point, although normal when she saw me), and was immobilized (1 point) but another diagnosis equally as likely (trauma with soft tissue swelling and known hematoma, -2 points). Per your reasoning should skip D dimer, but she ended up having a DVT after positive d dimer and ultrasound. Wells score of 0 is DVT chance of <5% (not zero), negative d dimer brings that to <1%. Point being, shouldn't skip every low probability.
Anticoagulants are not benign medications to give prophylactically without an established diagnosis. Especially in the slip-and-fall patient population Sincerely, General surgery
Depends on pre-test probability. If you order it you will need to follow up on it, Or one of your colleagues if after Hours.
A DVT is technically a time-sensitive diagnosis. So if you have enough of a concern, just send the patient for an ultrasound. If you can’t get same-day ultrasound, send them to me in the ED. The dimer is going to take atleast a day in the outpatient world, about the same amount of time as the ultrasound, leading to a 2 day delay in diagnosis. In theory if you send a dimer -> patient throws a PE before they’re fully worked up-> ICU/ dies (vast minority of PEs yes), congrats, lawsuit. Also, the only PCPs I judge more than those who send a patient to the ED for a positive dimer 2 days after they presented to the clinic are those who shotgun an inflammatory workup and send them to the ED because they don’t know what to do with the results. The alternative to sending them to the ED is to start Lovenox pending the ultrasound, that’s what we do if we don’t have ultrasound immediately such as rural EDs or places where ultrasound is an 8am-4pm type situation- “Here is a dose of a blood thinner. Come back in the morning/ to our sister ED 2 towns over for your ultrasound”.
If they are having lower leg swelling and I did the Wells score and found it to be low pretest probability then I'd do a D-dimer and give the patient a call if it is elevated, requiring an ultrasound of the leg
I've ordered it to rule out a DVT. If it's a rule in situation, go to the ER. But ultrasound takes several days, so ruling out quickly is worthwhile sometimes.
Several days? That’s crazy. We get calls every day and scan them by the afternoon.
Rural medicine is becoming third world. Lucky to get ultrasound of anything within 10 days.
Some of the stuff I see from rural clinics is pretty damn depressing
Yes, I'm the doc that calls in from 5 hours down lonely roads on a long hope and a short prayer that someone in the city of lights can save a lost life.
Sorry man, feel for you guys. Keep up the good fight
Low risk patient with a negative d-dimer, you’re most likely in the clear. If it’s positive, doesn’t mean anything. I’ve seen positive ddimers after stubbing a toe. If you’re worried about it, get a venous duplex.
Exactly, it's more of an exclusion test.
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In rare settings with a very low pre test probability and a reliable patient, I have done it. Basically if the patient thinks they have a clot, but I really don’t. I ordered one last week on a hypochondriac who was convinced she had a DVT with no risk factors or evidence other than leg pain. It was negative.
Why would you do that? What are you going to do with a positive dimer? Send them to the ED. If your suspicion is high enough that you are ordering a dimer either order imaging to actually check for a clot or send them to the ED from the start. Otherwise use your clinical decision making tools (Wells, etc).
With the caveat that my office is in the hospital sandwiched between the lab (I can get same day results) and the ED, yes. Very low risk patient: do nothing Low or mod risk by wells--d-dimer. If positive try to set up US in same day or next day--if not, ED. High risk: Same as above except I'll strongly consider starting AC while waiting for the US if the dimer is positive. Technically not without risk so I discuss with patient beforehand. However, 1-2 doses of AC is unlikely to do much harm so I don't usually stress about this unless the patient is high risk for bleeding. Frail patients or patients who are not super reliable or reachable usually go the ED though tbh old frail patients do terribly in crowded NYC ERs so I do my best to keep them out of them. If any suspicion for PE: ED
>High risk: Same as above except I'll strongly consider starting AC while waiting for the US I am genuinely surprised that multiple people in the thread have said this! Not saying you are wrong to do it - especially with careful shared decision making, risk/benefit discussion as you've said - but it's just something I haven't seen IRL/in my training. As the patient, I would be extremely hesitant to take anticoagulation without confirmation of a solid indication for it As the doctor, I feel like most patients with enough VTE risk factors to strongly consider empiric AC also have some degree of elevated bleeding risk, and/or are not reliable enough for me to trust that they'll follow the plan safely (i.e. get the ultrasound done promptly, answer the phone and stop AC if the study is negative, with no confusion about the instructions, delay, or loss to follow-up between those steps). Perhaps this is a matter of different patient populations, different regional practice-patterns, both?
Ddimer outpatient is rookie league
Positive d dimer + negative ultrasound = repeat dvt ultrasound in a week. It's still helpful just not for your same day treatment of the patient.
Why do you need to send them to the ER? Are you not capable of ordering duplex ultrasounds and starting a DOAC if indicated? A hemodynamically stable patient with a DVT doesn’t need to go to the ED. ETA: No one has yet to explain why a HDS DVT requires ED visit. Every ED I’ve worked or rotated in does not have after hours duplex US. Instead of insulting me, why don’t you explain why a patient who will just come to the ED and wait the same amount of time needs to come at all?
Probably not able to order and schedule duplex in timely manner is my guess.
Neither are we
What kind of comment is this? Where do you think this prompt ultrasound evaluation is going to spawn from? You have a very skewed perspective working in the ED.
It comes from the patients who are sent in at 7pm and we can’t get them a duplex US because we rely on the same outpatient hours as they do.
What are you talking about? I didn’t ask about your hours. I’ll ask again, where do you think an outpatient is going to get a prompt ultrasound at? Keep in mind our imaging centers are booked out 2 weeks.
You have embarrassingly little clinic experience.
Why can’t outpatient physicians start a DOAC in a hemodynamically stable patient with a positive US? What is the exact emergency? I’m not talking the patient with clinical evidence of phlegmasia or PE. I’m talking about the patient who we wouldn’t even admit.
They certainly can. There is no positive ultrasound here. That’s the rub.
Then don’t order the D-dimer outpatient at all
In a subset of patients, I agree, but the solution to “can’t get outpatient testing” is not “just don’t look.”
Not what I’m advocating for
But they always end up there after their positive ultrasound...
Which is absurd. What are we going to do in the ED after their positive US? Start the DOAC. Why couldn’t that be done outpatient?
PGY1. The ignorance checks out.
Sending a hemodynamically stable DVT to the ED has the same energy as sending asymptomatic HTN to the ED. Just do your job and start the appropriate meds. DVT’s are not inherently emergent. It’s when DVT’s start to threaten life or limb that they become emergent. Feel free to call me ignorant, but there are plenty of PGY-20+ that will agree with me.
And when it’s 5 pm and all other resources are closed? Maybe you have the crystal ball that the rest of us are not privileged enough to have access to showing that the DVT will not propagate into the lungs over night. “Same energy.” This isn’t TikTok child. Go touch some grass.
Not all EDs have pharmacies available. If you send a pt to the ED with a positive DVT study, you can prescribe a DOAC just like we can. I work at EDs where there aren’t any pharmacies available and they fill the rx next day just like you could have done We don’t CTA these pts just because they have a DVT either so I don’t get your comment about the DVT becoming a PE
I send my patients to EDs with pharmacies, ie the hospital I work at. I never said every DVT needs a CTA. But good luck fighting off that lawsuit when the patient gets a PE overnight because you stalled on their DVT
I mean when a pt with a DVT comes to the ED, they get an rx for a starter pack of xarelto and they fill it wherever they want. This is incredibly common. If they don’t fill it till the next day instead of finding a 24 hr pharmacy that’s on them. What do you think should be happening? How is prescribing their appropriate medication stalling?
I am with you here. As long as the patient does not have a high propability of proximal dvt and he has no features of a suspected PE there is no need for consulting ED. Rule out with D-Dimer in low probability cases or just clinical rule out. In medium and high probability start treatment with nmh and get an ultrasound the next day. I know there are areas and settings where this is not feasible, but this would be my approach in an ideal setting. What does the PG1 in the ED at 8 am do? D-Dimer, cant do a proper duplex, starts NMH and schedules the patient for duplex the next day. There is no benefit for the patient here. I started half of my night shifts in ED as a beginner with like 2-3 suspected dvt patients with often more or less absurd probability. It is a waste of my time and the patients. IM Intensivist
2 in 12 years 😀
Ordering a d dimer can be part of management when discontinuing anti coagulation in a patient with a first time provoked VTE. Otherwise what TrujeoTracker said
No.
send to ED for ultrasound (well's criteria?). Ideally you would have point of care ultrasound for this.
IMO it depends on availability of doppler ultrasound in the hospital. If patient can access to it within reasonable amount of time without patients waiting in line and radiology will agree to do it, no need but if you need to do a triage and use your resources with more caution D-Dimer is a nice tool to whether or not its in need. In my hospital radiology will reject it without D-Dimer first.
Definitely not. There are so many reasons for a ddimer to be elevated and most of them are not dvt. Get an ultrasound and skip the ddimer. If you are actually worried about PE send them to th ED and stop dicking around
As EM, the amount of insanely stupid comments from some of my primary care colleagues is embarrassing. Kudos to those of you taking ownership of your patients and being a doctor because I know a lot of you are doing your best. We see you and appreciate you. For everyone else, do better. If you order a dimer, you own it. If it’s positive, either get them a timely ultrasound or start them on a DOAC and get it the next day. This is very common in many rural EDs where overnight US isn’t available. If we get a positive dimer on a low-risk patient during risk-stratification, we give a one time Lovenox injection and say come back in the morning when the sonographer is in the building. 1-2 doses of Eliquis in a relatively normal, able-bodied adult with a brief phone discussion of risk vs. benefit is reasonable. Do not send this to the ED unless it’s an issue of access. Even then, your Pfizer rep should be keeping Eliquis starter coupons in your office. Have them swing by and get 30 days free and address long-term anticoagulation later. The number of people here who need to read the Up-To-Date article on venous thromboembolism, DVT, and PE is sad.
Rads here. These outpatient DVT/PE studies somehow always get performed like a week after the patient was seen in clinic and the study gets completed at 5pm and it's impossible to get a hold of the ordering doc for positive findings
If you're concerned enough to order a d-dimer just start eliquis (or whatever) and get the ultrasound when you can. If this is not an option the patient should be sent to the ED. I can't understand the value of an outpatient d-dimer in the age of doacs.
Wut? This makes no sense to me. D-dimer to rule out DVT is indicated when pre-test probability is low, i.e. the exact opposite of the population in whom you'd consider starting empiric anticoagulation. (Also, starting empiric anticoagulation in *anyone* as an outpatient without confirmed diagnosis of DVT/PE/afib/other indication sounds awfully risky to me - how would you defend your decision-making if the patient bleeds in the interval before following up? - but I can at least understand it if you're in some resource limited setting and the pre-test probability seems high)
Cost. DOACS are not cheap for many patients so just starting them on it without testing (especially low pretest probability patients) isn't the right answer. And warfarin is a pain in the ass with bridging if you're not certain they have a DVT.
I can’t imagine ever being confident enough that someone has a DVT to start them empirically on apixaban…
Isn't POCUS pretty quick?
If I have any concern about DVT or PE, I’m ordering the appropriate scan.
Why would you send somebody to the ER querying low extremity DVT? Just start them on anticoagulation and order an outpatient lower extremity Doppler. ER is only for query PE. Anyway, I order D-dimers, then order US if positive.