1(E): PE Flashcards
Define a PE
Occlusion pulmonary arteries by solid, gas or liquid matter
What is the most common cause of PE
Thrombus from DVT
Explain incidence of PE with age
Increases with age
What factors increase incidence of PE
- Malignancy
- Active Inflammation: IBD
- Surgery - particularly to lower limbs
- Immobility
- pregnancy
- COCP
- HRT
what is the typical triad of symptoms in PE
- Haemoptysis
- Dyspnoea
- Pleuritic chest pain
what is a saddle embolus
Large embolus that occludes bifurcation of pulmonary arteries
how may a saddle embolus present
Shock
what is the most common sign of PE
Tachypnoea (90%)
what may be seen on observations in PE
- Tachypneoa
- Tachycardia
- Fever
what may be ausculated in PE
Crackles
Loud S2
Pleural Rub
what may be seen on palpation in PE
Raised JVP
Right ventricular heave
why does a pleural rube occur
Inflammation pleura cause loss fluid between and friction as they rub together
when should PE always be considered as a differential
Sudden-collapse in person two weeks after surgery
where do majority of PE’s arise
DVT above the knee
what should be done first in PE
decide whether individual is at high or low-risk of death
how is it deiced whether individual with a PE has a high or low risk of death
High risk of death includes:
- Systolic BP less than 90
- Decrease in systolic BP of 40 in 15m
if a low-risk of death, how is the person assessed
Modified wells score
what is mnemonic to remember components of the modified wells score
SHRIMPA
what are the components of the modified wells score
Signs and symptoms of DVT
Haemoptysis
Rate of heart >100
Immobility
Malignancy (Palliative, Treatment in past 6 months)
PMH DVT or PE
Alternative diagnosis less likely
in the modified wells score - what defines high risk of PE
More than 4
how are individuals with high probability of PE investigated
CTPA
what should be checked before CTPA
RFTs
what is a contraindication to CTPA
Contrast Allergy
Poor Renal Function
if GFR less than 35 or contrast allergy, what is used
V-Q scan
what defines low risk of PE
less than 4
if individual is low risk of PE what is performed
D-Dimer
if D-dimer is positive, what test is performed to confirm PE
CTPA
aside from d-dimer, CTPA, what investigation may be ordered for PE
ECG
what is the most common sign of PE on ECG
Sinus tachycardia
what other sign of PE can be seen on ECG
- S1T3Q3
- Right bundle branch block with right-axis deviation
if suspected delay in CTPA, what should be given
LMWH or fondaparinux
in PE, what is first line management
Oxygen
what drugs are given to all individuals with PE
Morphine
IV LMWH/ Fondaparinux
if someone has a creatinine clearance of less-than 15 what is given as an alternative to LMWH
Unfractioned heparin
if individual with massive PE, how are they managed
- Resuscitation if in shock
- Thrombolysis with alteplase
what is first line if a non massive PE
Rivaroxaban
If PE is confirmed, how long should rivaroxaban be continued for
3W.
Also calculate pulmonary embolism severity index
What is an alternative to rivaroxaban
Warfarin
If a provoked PE, how long is warfarin continued for
3-months
If an unprovoked PE or active cancer, how long is warfarin continued for
6-months
how long should LMWH be carried on for
5-days or until 24h after INR is greater than 2.0 = whichever is longer
summarise management of PE
- Oxygen
- LMWH
- Morphine
- If haemodynamically unstable resuscitate and thrombolyse. If not, give rivaroxaban or warfarin
how are recurrent PE’s managed
Inferior vena cava filter
what is used to determine severity of PE
Pulmonary Embolism Severity Index (PESI)
what happens to PESI class I and 2 individuals
Early discharge
What happens to PESI class 3,4 and 5 individuals
Further test with troponin T, ECG and eCHO
what are 5 risks of PE
- Recurrence
- RVF
- Sudden cardiac death due to PEA
- Atelectasis
- Pulmonary infarction caused by embolism if segmental arteries = causing wedge shaped haemorrhage pulmonary infarction
