B4.030 - CBCL Pulmonary Embolism Flashcards
If you suspect a patient has DVT what should you use in your assessment
Wells criteria
If the patient has a low probability for DVT what should you do
Obtain D-dimer to exclude DVT if normal
If the patient has a high probability for DVT what should you do
Obtain a lower extremity ultrasound (highly sensitive and specific) to evaluate for presence of a DVT and its site of involvement/thrombus burden if present
if you suspect a patient has PE what should you do
Obtain CXR
if you suspect a PE and the CXR doesn’t demonstrate an obvious reason for the patient symptoms that would exclude PE
get a CTA of the chest or V/Q lung scan if CTA is contraindicated
if a patient has experienced blunt thoracic trauma what should you start with
CXR
if a patient has experienced blunt thoracic trauma that was low to moderate and the CXR is normal
It can stop here if nothing concerning on CXR
if a patient has experienced blunt thoracic trauma and X ray is positive
procede to CT
how should penetrating chest trauma be evaluated
by both CXR and CT
what do the green and blue arrow point to
blue - true lumen
green - false lumen
what are the yellow arrows pointing to
pericardial effusion
what is pictured here
intimal flap dissection involving the ascending and descending thoracic aorta
what is a type A aortic dissection
involves ascending aorta
what is a type B aortic dissection
involves descending aorta (originating after takeoff of brachiocephalic artery)
epidemiology of aortic dissection
peak age 50-65
male>female
signs and symptoms of aortic dissection
Tearing/ripping chest pain
back pain
aortic insufficiency
BP difference between arms
complications from aortic dissection
cardiac tamponade
carotid involvement
coronary involvement
management of type A artic dissection
surgical management
type B aortic dissection management
usually medical
consider surgery if organ hypoperfusion or shock
if you have a patient (older male with tearing chest pain radiating to the back) what should you do
- obtain CXR
- if CXR does not demonstrate an obvious reason for pain it excludes dissection
- obtain CTA
what is this + for
Pulmonary embolism
what is this + for
right heart strain sign of hemodynamically significant PE
what is an IVC filter
metallic basket placed in IVC to catch emboli from lower body veins
can be placed in patients with DVT to prevetn PE
or
PE with or without DVT
what are absolute indications for IVC filter in patients with DVT/PE
contraindication for anticoagulation
recurrent PE in spite of anticoagulation
anticoagulation-related complication
what are relative indications for IVC filter
- free floating thrombus in IVC or iliofemoral segments
- pE and limited cardiac reserve
- prophylaxis in pts wiht severe trauma who cant walk
- prophylaxis for surgery in pts with DVT
- poor compliance with anticoagulation
- protection druing DVT
where should IVC filters be placed
below renal veins because they dont have collateral flow
when do IVC filters come out
when no longer needed
IVC filter complications
migration
limb fracture
IVC rupture
Pierce adjacent viscera/aorta
IVC thrombiss lead sot increased lower exterminty venous stasis and DVTs
what are Wells criteria
what does a D Dimer test for in the body
fibrin
What imaging study will be the most sensitive and specific in detection of mediastinal hematoma?
CT of chest
What is a common presentation for infants with severe aortic coarctation?
Weak femoral pulse and possible cardiac murmur
Describe the conditions at the top of the normal upright lung?
At the top of the lung, PAO2 and VA/Q are higher than at the bottom of the lung, while alveolar ventilation and PACO2 are lower than at the bottom of the lung.
A 22-year-old woman with previously normal pulmonary function is admitted to the ER at KUMC and now has the following data breathing room air:
PaO2 = 85 mm Hg
PaCO2 = 43 mm Hg
Arterial pH = 7.36
PECO2 = 14 mm Hg
Respiratory frequency = 24 breaths / min (normal for this person: 14 / min)
Tidal volume 700 ml (normal for this person: 450 ml)
These data indicate that this patient has what condition?
Acute Pulmonary Embolism
The key variable here is the high VD/VT = (PaCO2 - PECO2) / PaCO2 = 0.6 (normal 0.20 - 0.35). The air coming from the alveolithat are not perfused (because of the embolism) has no CO2 and “dilutes” the PECO2.
Aortic dissection is suspected in a 64-year-old male. What is the most appropriate test to confirm the diagnosis?
CTA, MRA, and TEE have similar sensitivity and specificity for evaluation and confirmation of aortic dissection. CTA is usually obtained because fast and cost-efficient. MRA may be used with renal failure or iodine allergy. TEE is user dependent and may take longer to obtain. A chest x-ray is often performed initially in order to rule out other causes of the chest pain, but is not confirmatory for aortic dissection.
describe the usefulness of a D dimer
high negative predictive value
The American College of Radiology’s (ACR) Appropriateness Criteria take into account a given study’s what 2 features when making a recommendation regarding what particular imaging study should be ordered for a patient?
Safety
diagnostif efficacy
JJ is a 40-year-old female with history and physical examination findings suspicious for lower extremity DVT. She undergoes a lower extremity ultrasound examination for further evaluation. A typical lower extremity ultrasound examination utilizes how many different tests to evaluate for a DVT?
3
A standard lower extremity ultrasound examination ordered for the evaluation of DVT includes:
Venous compression
Color Doppler
Duplex Doppler
what imaging studies is the most accurate for diagnosing a PE?
A chest radiograph can be performed to evaluate for pneumonia or pneumothorax, but a CTA of the chest is most accurate for diagnosing PE. If the patient is allergic to IV contrast or has renal insufficiency (placing them at increased risk for renal failure from IV contrast) a V/Q lung scan may be performed.
where is the appropriate place to place an IVC filter
B
when would be the most appropriate time/setting to schedule a patient to have his/her retrievable IVC filter removed?
At the time of discharge to home from a rehabilitation facility after recovering from traumatic intracranial hemorrhage.
The IVC should be removed when the hemorrhage has been resolved, and surgery and rehabilitation has been completed.
absolute indications for placing an IVC filter
Absolute indications for IVC include:
contraindication for anticoagulation (not poor patient compliance),
recurrent PE in spite of anticoagulation,
and anticoagulation-related complication.
KF is a 30-year-old male who presents with right lower extremity pain. He was recently released from the hospital after being admitted for several days for treatment following a motor vehicle accident. What factor places him at greatest risk for a lower extremity DVT?
Obesity, smoking, and varicose veins are minor risk factors for developing DVT. Age is not a significant risk factor for DVT in patients less than 60 years of age. Recent trauma is a major risk factor for developing DVT.
SH is a 34-year-old-female who presents with a massive PE and evidence of right heart strain. What is the most appropriate next step in the treatment of this patient?
Emergent catheter-directed thrombolytic therapy/embolectomy.
This is performed in cases where systemic signs of right heart failure are observed.
JW is a 58-year-old-male who presents with chest pain. He is diagnosed with a type B aortic dissection. What was his biggest risk factor for developing an aortic dissection?
Hypertension is considered as the most important risk factor for aortic dissection and is present in about 80% of patients with aortic dissection.
