4) PE Flashcards
Causes of PE?
Usually arise from a VT in the pelvis or legs
Rare causes: RV thrombus (post MI), septic emboli, fat, air, amniotic fluid, tumour, parasites
Risk Factors for PE?
Recent surgery Thrombophillia eg antiphospholipid syndrome leg fracture prolonged bed rest/reduced mobility malignancy pregnancy/post partum/ pill/ hrt previous PE
Clinical features of PE?
depend on size and distribution: small can be asymptomatic, large sudden death
Acute breathlessness, pleuritic chest pain, haemoptysis, dizziness, pyrexia, tachy (both), hypotension, raised JVP, low cap refil
look for sign of dvt
Tests in PE?
Depend on the wells score really
FBC, U+E baseline clotting
ABG may show low o2 and CO2
CXR: may be normal, wedge opacity, small effusion, linear atelectasis
ECG: normal, tachy, RBBB RV strain (inverted T 1-4) S1Q3T3 rare
What type of resp failure can you get in PE?
Type one due to V/Q mismatch
Ix that can be done in PE?
U+Es, clotting, FBC
D Dimer- low specificity but high sensitivity- good for exclusion
CTPA- Gold standard
What else can raise a D Dimer?
Thrombosis, pregnancy, infection, malignancy
Management of Large PE?
Oxygen if hypoxic
Morphine 5-10mg if distressed
Consider 50mg alteplase if periarrest
IV access and start heparin, LMWH of UFH
Check BP:
If <90, start fluids and contact ICU
If <90 after 30-60 mins and defs and no C/I then thrombolise
if >90
Start warfarin eg 5-10mg PO and continue until inr 2-3
Management after stabilisation of PE?
- Prevent further embolism with compression stockings
- LMWH with warfarin until INR 2-3
- If obvious cause, then continue for 6 weeks
- No obvious cause, continue for 6 months, longer if malignancy
When do most deaths occur in PE?
Within the first hour, get on and treat it
Prevention of PE?
Early post op mobilisation is the best method
Also: TED stockings
LMWH
Avoid OCP if at risk
How do we decide if a PE is likely?
WELLS SCORE: S+S of DVT? 3 Alt diagnoses less likely? 3 HR>100 1.5 Immobile 3 days/surgery<4weeks 1.5 previous 1 Haemoptysis 1 Malignancy 1
What is the Wells cut off?
more than 4 is likely
management if PE likely?
CTPA, if there will be a delay, give LMWH in meantime
Management if PE unlikely?
DO a d dimer, if -ve happy days, if +ve CTPA and anticoagulate