8. MTB Step 3 - Pulmonary Embolism (PE) Flashcards
Cards Complete:
PRESENTATION
What is a typical Clinical Presentation for Pulmonary Embolism (PE)?
Sudden onset of SOB
+
Clear Lungs on auscultation
+
DVT Risk Factors
There are NO specific physical findings for PE.
PRESENTATION
What are (5) Risk Factors for Deep Venous Thrombosis (DVT)?
- Immobility
- Malignancy
- Trauma
- Surgery (especially Joint Replacement)
- Thrombophilia (factor V mutation, lupus anticoagulant, protein C & C deficiency)
DIAGNOSIS
CXR
- What is the Most Common result on Chest X-Ray (CXR) for Pulmonary Embolism (PE)?
- What is the Most Common Abnormal result on Chest X-Ray (CXR) for Pulmonary Embolism (PE)?
- Normal CXR
- Atelectasis
DIAGNOSIS
ECG
- What is the Most Common finding on ECG for Pulmonary Embolism (PE)?
- What is the Most Common Abnormal finding on ECG for Pulmonary Embolism (PE)?
- Sinus Tachycardia
- Nonspecific ST - T wave changes
DIAGNOSIS
ABG
What are (3) Finding on Arterial Blood Gas (ABG) for Pulmonary Embolism (PE)?
- Hypoxia
- Increased A - a gradient
- Mild Respiratory ALKALOSIS
SAMPLE QUESTION
PE
“A patient who has recently undergone hip fracture repair develops the sudden onset of shortness of breath. His pulse is 110 per minute. The chest is clear to auscultation. Chest X-Ray is Normal, and the ECG shows Sinus Tachycardia. ABG shows pH 7.48, pCO2 28, pO2 75.”
What is the Next BEST Step in management?
Heparin
When the case so clearly suggests a pulmonary embolus with sudden onset of shortness of breath and clear lungs in a patient with a risk factor, the first thing to do after the chest x-ray and blood gas is to start HEPARIN. Do not wait for the results of V/Q scan or Spiral CT to start Heparin.
DIAGNOSIS
Which Test is considered the Gold Standard to Confirm the presence of a Pulmonary Embolus (PE)?
CT Angiogram (CTA)
- High Sensitivity & Specificity
- The clear Test of Choice IF the CXR is Abnormal
DIAGNOSIS
Which Test should ONLY be done if there is an Absolute Contraindication to the Gold Standard test for confirming Pulmonary Embolus (PE)?
V/Q Scan
- For V/Q Scan to be accurate, the CXR must be normal.
- Only truly normal scans can exclude a PE.
- 15% of low-probability scans still have a PE.
- 15% of high-probability scans don’t have a PE>
DIAGNOSIS
Which Test is excellent for confirming Pulmonary Embolus (PE) ONLY if it is positive?
LE Doppler
- However, 30% of PEs originate in pelvic veins (will give a normal LE Doppler Scan)
DIAGNOSIS
What test commonly used in Pulmonary Embolism (PE) has Very High SENSITIVITY but Poor SPECIFICITY?
D - DIMER
The BEST use of D-Dimer Testing is in a patient with a Low Probability of PE in whom you want a single test to exclude PE
DIAGNOSIS
What is the single Most ACCURATE Test for Pulmonary Embolism (PE)?
Angiography
- Unfortunately, angiography is invasive with a significant risk of death of about 0.5%.*
- Thanks to CTA, angiography with a catheter rarely ever the best answer.*
SAMPLE QUESTION
“A 45-yo man comes to the ED after a MVA resulting in a liver hematoma. On the third hospital day, he becomes suddenly SOB. His CXR is normal, and he is diagnosed with PE.”
What is the Next BEST Step in Management?
Inferior Vena Cava Filter
- When a patient has a PE and there is a contraindication to anticoagulation, an IVF should be placed.*
- This patient has a liver hematoma, so a filter should be placed.*
TREATMENT
What are the (2) Standard of Care treatments for Pulmonary Embolism (PE)?
-
Enoxaparin (LMWH) + Oxygen, followed by Warfarin
- OR
- NOAC from the start (Hemodynamically stable patients are best treated with a NOAC)
TREATMENT
What are (4) NOAC drugs?
- Rivaroxaban
- Edoxaban
- Apixaban
- Dabigatran
TREATMENT
What class of Medication has equal efficacy to Warfarin, but with Less Intracranial Bleeding and without the need for INR monitoring?
NOACs
(Rivaroxaban, Edoxaban, Apixaban, Dabigatran)
- Used in Hemodynamically Stable patients.*
- Don’t need initial treatment with LMWH.*
TREATMENT
When are Thrombolytics used in the treatment of Pulmonary Embolism (PE)?
Hemodynamically Unstable
- Hemodynamic Instability = Hypotension*
- Thrombolytics essentially replace Embolectomy, which is rarely performed due to high operative mortality.*
- No precise time frame for using Thrombolytics in PE (like with MI)*
