Of Dimers and DVTs

[RustedFox]

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[insert "change my mind" meme pic here, I'm too lazy to edit the image]

A negative d-dimer does not rule out DVT.
Change my mind.

Sure, I've read the studies where it says: "LoLz, Yes it does".

But a categorically low-risk patient is needed to do that.

Let's look at the Wells criteria for DVT.

"Do you have a finding? Any finding? Any history of any risk factor? Does the patient have LEGS?"

Ok, you're no longer low risk.

Just order the ultrasound and stop playing this game.

 

[xaelia]

Eh, it's not gonna rule it out, but the failure rate is going to be about 1 in 1000 for your low-risk patient and 1 in 300 for your non-low risk patient.

I suspect your real barrier is ultimately going to be blowback from payors who entangle you in "not medically necessary" reimbursement issues if you have normal D-dimer on the chart.

 

[Mbekweni]

D dimer and bedside US when the vascular tech calls out sick. Community EM where this happens from time to time. It’s the next best thing. Otherwise formal study.

 

[Mount Asclepius]

In reading the themes on the Wikipedia page of Steinbeck’s book it is eerily similar to the plight of the emergency physician living and trying to make it in the pit ordering various testing (I’m assuming the inspiration behind the thread title).

 

[TooMuchResearch]

I just get the radiology ultrasound. I do not f around with my own ultrasound.

 

[Apollyon]

How about an INR of 4.3 and a PE?

Throw in pregnant, and that's how I punted that to Ob/Gyn.

 

[johhnybgood]

I’m done at nega

[insert "change my mind" meme pic here, I'm too lazy to edit the image]

A negative d-dimer does not rule out DVT.
Change my mind.

Sure, I've read the studies where it says: "LoLz, Yes it does".

But a categorically low-risk patient is needed to do that.

Let's look at the Wells criteria for DVT.

"Do you have a finding? Any finding? Any history of any risk factor? Does the patient have LEGS?"

Ok, you're no longer low risk.

Just order the ultrasound and stop playing this game.

[insert "change my mind" meme pic here, I'm too lazy to edit the image]

A negative d-dimer does not rule out DVT.
Change my mind.

Sure, I've read the studies where it says: "LoLz, Yes it does".

But a categorically low-risk patient is needed to do that.

Let's look at the Wells criteria for DVT.

"Do you have a finding? Any finding? Any history of any risk factor? Does the patient have LEGS?"

Ok, you're no longer low risk.

Just order the ultrasound and stop playing this game.

Im done at negative d dimer.

Unless extenuating circumstances just advise if something changes to come back for reassessment.

I follow bounce backs closely and in 9+ years as attending I’ve not had a negative dimer and serious subsequent outcome for + PE or dvt. I think if you are doing ct or us despite negative dimer and low to medium risk wells you are doing a lot of over testing.

 

[watermanMD]

U/S is only like 95% sensitive for DVT. And ~1-2 out of 100 will have false negative. We should be ordering the gold standard (venography) on everyone….KIDDING about that last part.

 

[JacobMcCandles]

If you're at a place where you have easy access to ultrasound then I just get the ultrasound. It's not great medicine but it's a generally low risk test and patients think they need one anyway and you'll never convince most that they don't, especially the ones who were in a car for 2 hours recently but lay in a bed for 8 hours a night every night. If it's at night or you don't have ultrasound immediately available then feel free to get a d-dimer and if it's elevated just give them a shot of lovenox and have them come back in the morning for a formal ultrasound.

 

[Groove]

Pre-test probability low and can't PERC = dimer and if negative I'm done.
Pre-test probability anything other than low = no dimer, US or CTA for dispo

Occasionally, I might have a PERC neg pt that just needs reassurance and in those cases I might do a bedside "abracadabra" US. Clinical gestalt for everything else. In general though, I don't really order that many dimers because they kill LOS and are such a crap shoot.

I get a lot of "Dr. Google said I might have a DVT!" pts that want an US and the fastest way for me to dispo them is usually just skipping labs and getting the US which is what I do most of the time. Our community gig is an affluent crowd, so I have to baby them a bit more than other sites.

@RustedFox Weren't you raving about the value in age adjusted dimers not too long ago for all your old people? Or am I thinking about someone else?

 

[RustedFox]

I was ranting (which is what I do)
But I'm taking DVT here, not PE. Different ballgame, same series.

Old person just might BENEFIT from "GTFO" (either to the floor, or home) without a CTA.

 

[ERMudPhud]

One of the places I work I can't get a DVT US from 4pm on Friday until 8AM on Monday. So if dimer and my bedside US negative. Home on nothing and told to come in for formal US on Monday. If dimer or my US positive home on eliquis and come back Monday for formal US.

 

[PB2464]

One of the places I work I can't get a DVT US from 4pm on Friday until 8AM on Monday. So if dimer and my bedside US negative. Home on nothing and told to come in for formal US on Monday. If dimer or my US positive home on eliquis and come back Monday for formal US.

I hope you're getting paid for that bedside US.

 

[Siggy]

How about an INR of 4.3 and a PE?

Throw in pregnant, and that's how I punted that to Ob/Gyn.

How was her liver?

 

[TooMuchResearch]

One of the places I work I can't get a DVT US from 4pm on Friday until 8AM on Monday. So if dimer and my bedside US negative. Home on nothing and told to come in for formal US on Monday. If dimer or my US positive home on eliquis and come back Monday for formal US.

Can't get ultrasound? Dark ages.

 

[RustedFox]

One of the places I work I can't get a DVT US from 4pm on Friday until 8AM on Monday. So if dimer and my bedside US negative. Home on nothing and told to come in for formal US on Monday. If dimer or my US positive home on eliquis and come back Monday for formal US.

Can't get ultrasound? Dark ages.

You're both not wrong.
Unfortunately, it's like this in a lot of places, including mine.

 

[Angry Birds]

U/S is only like 95% sensitive for DVT. And ~1-2 out of 100 will have false negative. We should be ordering the gold standard (venography) on everyone….KIDDING about that last part.

Venography is not 100 percent sensitive either. That’s why I just treat them all with immediate tpa

 

[TooMuchResearch]

You're both not wrong.
Unfortunately, it's like this in a lot of places, including mine.

Huh, I honestly wouldn't consider working in such a place but am, admittedly, spoiled.

 

[RustedFox]

Venography is not 100 percent sensitive either. That’s why I just treat them all with immediate tpa

See? SEE!

NOW you're fuggin' TALKING, broh.

 

[RustedFox]

Huh, I honestly wouldn't consider working in such a place but am, admittedly, spoiled.

"DO YOU EVEN THROMBOLYSIS, BRO?!"

 

[Apollyon]

How was her liver?

This was over 20 years ago, but, as I said, pregnant. But no HELLP syndrome.

 

[TooMuchResearch]

"DO YOU EVEN THROMBOLYSIS, BRO?!"

Thrombolytics all day everyday.

 

[RustedFox]

Thrombolytics all day everyday.

I do pre-thrombolytics, even.
Generally 1 hour before my workout.

 

[Siggy]

This was over 20 years ago, but, as I said, pregnant. But no HELLP syndrome.

There's also acute fatty liver of pregnancy. I'm just spitballing other reasons to have an elevated INR, especially elevated and pro-thrombotic.

 

[Angry Birds]

Venography is not 100 percent sensitive either. That’s why I just treat them all with immediate tpa

I forgot to mention that I order the venogram after the thrombolytic to make sure it’s resolving.

 

[Tenk]

[insert "change my mind" meme pic here, I'm too lazy to edit the image]

A negative d-dimer does not rule out DVT.
Change my mind.

Sure, I've read the studies where it says: "LoLz, Yes it does".

But a categorically low-risk patient is needed to do that.

Let's look at the Wells criteria for DVT.

"Do you have a finding? Any finding? Any history of any risk factor? Does the patient have LEGS?"

Ok, you're no longer low risk.

Just order the ultrasound and stop playing this game.

Even a wise penitent like myself just orders an ultrasound.

 

[RustedFox]

Even a wise penitent like myself just orders an ultrasound.

I finished the DLC about a week ago.
Honestly, I kind of felt it was disappointing. The two new areas were cool, but the quests felt "shoehorned in".

 

[Tenk]

I finished the DLC about a week ago.
Honestly, I kind of felt it was disappointing. The two new areas were cool, but the quests felt "shoehorned in".

I forgot I never finished it until I saw your post. I think I’ll have to start over at this point. So far I didn’t like it as much as 1 though.

 

[RustedFox]

I forgot I never finished it until I saw your post. I think I’ll have to start over at this point. So far I didn’t like it as much as 1 though.

Get the DLC.