13. Pulmonary Embolism

Question 1

What is a pulmonary embolism?

Answer 1

They arise from venous thrombosis in the pelvis or legs. Clots pass through the right heart into the pulmonary circulation.

Question 2

What are the risk factors for PE

Answer 2

Recent surgery
Thrombophiia (antiphospholipid syndrome)
Leg fracture
Prolonged bed rest/reduced mobility
Malignancy
Pregnancy/postaprum combined contraceptive pill, HRT
Previous PE

Question 3

What are the rarer causes of a PE

Answer 3

RV thrombus (post MI), septic emboli, (right sided endocarditis), neoplastic cells, parasites

Question 4

What are the symptoms of a pulmonary embolism

Answer 4

Acute breathlessness, pleuretic chest pain, heamoptysis, dizziness, syncope

Question 5

What are the signs of a pulmonary embolism

Answer 5

Pyrexia, cyansis, tachypnoea, tachycardia, hypotension, raised JVP, pleural rub, PE
DVT

Question 6

What tests can be done when a PE is suspected?

Answer 6

FBC, U&E’s, d-dimers
ABG (type I resp failure)
CXR- may show hypovoleamia of affected segment, dilated pulmonary artery, small PE, wedge shaped cavitations or opacifications
V/Q scan can be very useful in diagnosis especially in pregnant woman
ECG- may be normal, shwo tachycardia, right bundle branch block

Question 7

What scoring system is the best to use for those who have suspected PE?

Answer 7

Modified clincial wells score:

Clinical signs and symptoms of DVT- 3
Heart rate >100 - 1.5
Recently bed ridden >3 days <4 weeks-1.5
Previous DVT or PE-1.5
Haemoptysis-1
Active cancer-1
Alternative diagnosis is less likely than PE- 3

Question 8

What is the threshold of treatment of the Modified clinical wells score?

Answer 8

Score >4- CTPA and LMWH as empirical treatment
Score <4- do D-dimer
D-dimer positive do CTPA and LMWH

Question 9

How should you treat someone who has renal problems?

Answer 9

Treat with warfarin for 5 days then switch to DOAC or warfarin

Question 10

How do you treat someone who is heamodynamically unstable

Answer 10

thrombolyse for massive PE-

Question 11

How long should you continue treatment on anticoagulants after a PE?

Answer 11

Provoked: 3 months and then re-assess risk factors
Unprovoked:>3 months
Malignancy-6 months are until cure of cancer
Pregnancy- until delivery/end of pregnancy

Question 12

What are direct oral anticoagualants?

Give some examples

Answer 12

Alternative to warfarin, although there are limited antidotes for DOAC’s

Examples- dabigartan, rivaroxaban, apixaban