15 Pulmonary Embolism Flashcards
Most VTEs diagnosed in the ED are:
Provoked or Unprovoked?
Unprovoked / idiopathic
What are provoked VTEs?
a consequence of a triggering risk factor for clots, such as:
- recent surgery
- trauma
- limb or body immobility
- active cancer
- conditions that impede venous blood flow
Patients without prior heart or lung disease generally begin to experience symptoms from PE with at least ____% of lung vasculature occluded
20%
With larger clot burden, the pulmonary arterial pressure increass, leading to RV dilation and myocardial damage, causing the release of troponin and B-type natriuretic peptide
CXR findings in pulmonary embolism
Westermark’s sign
Hamptom’s hump
ECG findings in pulmonary embolism
S1Q3T3
“McGinn-White sign”
large S wave in lead I
Q wave in lead III
inverted T in lead III
These indicate acute right heart strain
This well score needs d-Dimer first
2-4
PE is likely if Wells is
> 4
Give LMWH if no contraindication
Proceed with imaging
EGFR ≥60: CTPA
EGFR <60: V/Q planar scan
remarks on PERC rule
all 9 factors must be fulfilled for PE to be excluded
Original Wells scoring
3 suspected DVT
3 Alternative dx less likely
1.5 HR >100
1.5 previous VTE
Surgery/immoblization within prior 4 weeks
1 Active malignancy
1 Hemoptysis
DVT algorithm
≥1: US
≤0: d-Dimer
Anticoagulation for PE
Heparin 80 units/kg IV bolus, then 18 units/kg/hour
Enoxaparin 1 mg/kg SC every 12 hours or 1.5 mg/kg SC every day
thrombolysis in PE
Alteplase 10 mg IV bolus, followed by 90 mg infused over 2 hours
Other treatment for pE
Fondaparinux 7.5 mg SC every day
Apixaban 10 mg BID for 7 days, then 5 mg BID
Dabigatran 150 mg BID
Massive PE
SBP <90 for 15 minutes
SBP <100 for those with hx of hypertension
>40% reduction of baseline hypertension
Submassive PE
Normal or near-normal BP but with other cardiopulmonary stress
