CBL 5: A Patient with Breathlessness Flashcards by patrick ellis

What are the differential diagnoses you may consider based on the given
history alone?

Pneumonia
Hypertension
Pleuritis
ACS

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How does a PE present?

Haemoptysis
Dyspnoea — this is the most common feature and is present in 50% of people with PE
Pleuritic chest pain — present in 39% of people with PE; Pain is normally localised to one side.
Cough — present in approximately 23% of people with PE.
Syncope or pre-syncope
Tachypnoea — present in 21-39% of people with PE.
Features of deep vein thrombosis (DVT)
Retrosternal chest pain (due to right ventricular ischaemia).

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Describe the heart sound often occurs in PE [1]

Gallop rhythm, a wide split-second heart sound, tricuspid regurgitant murmur.

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How does ACS present differently in females? [1]

Present atypically:
- epigastric or back pain or pain that is described as burning, stabbing, or characteristic of indigestion

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Which populations present atypically with ACS? [2]

Women
Diabetes patients

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Q4. Identify the terms you would like to learn about and to discuss.
Q5. What is your interpretation of the given signs?
Q6. What are the main priorities of management now?

ABCDE
A:
- Given she’s talking, her airways are fine

B:
- She has high resp. rate
- Give 15L oxygen
- Examine the chest for breath sounds: see if equal chest expansion, percuss and listen to breath sounds

C:
- PC: Tachycardia, central cyanosis, hypotensive
- Give 500ml 0.9% NaCl STAT (less than 15mins)
- (Stop amlodopine anti-hypertensives for acute attack)

D:
- Leg swollen - check for pitting oedema
- Check GCS
- Check blood glucose (i.e. for DKA - probably not for this case, but need to consider)
- Temperature

E
- Leg swollen, squeeze calf - see it patient complains [? why]
- Check pulses

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What type of shock is the patient potentially in?

Obstructive shock

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This patient is haemodynamically unstable. What does this mean? [1]

SBP < 90 mmHg

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Q8. Which specific investigations are indicated and useful?

CXR:
- Want to exclude pneumothorax and other pathologies

CTPA

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What is the management plan if you suspect a PE but the Wells Score < 4? [2]

Offer a D-dimer test with the result available within 4 hours

If the D-dimer test is positive:
arrange admission to hospital for an immediate CTPA and, where necessary, other investigations

If the D-dimer test is negative
- Stop interim therapeutic anticoagulation (if appropriate).
- Advise the person that it is not likely that they have a PE, but discuss the signs and symptoms, and when they should seek further medical help.
- Consider an alternative diagnosis.

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Q7. What specific medication(s) you may administer before the investigations
being done?

Administer:
- IV Alteplase: anti-fibrinolytic. Preferred because shes haemodynamically unstable

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Name 4 other pathologies that can cause raised D Dimer? [5]

Pneumonia
Malignancy
Heart failure
Surgery
Pregnancy

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What do you do if want a CTPA because you suspect a PE, but it takes ages to occur? [1]

Start treatment

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There are three imaging options for establishing a diagnosis of a pulmonary embolism [3]

There are three imaging options for establishing a diagnosis of a pulmonary embolism:

CT pulmonary angiogram (the usual first-line)

Ventilation-perfusion single photon emission computed tomography (V/Q SPECT) scan:
- Ventilation-perfusion (VQ) scan involves using radioactive isotopes and a gamma camera to compare ventilation with the perfusion of the lungs.
- First, the isotopes are inhaled to fill the lungs, and a picture is taken to demonstrate ventilation
- Next, a contrast containing isotopes is injected, and a picture is taken to illustrate perfusion
- The two images are compared.
- With a pulmonary embolism, there will be a deficit in perfusion as the thrombus blocks blood flow to the lung tissue. The lung tissue will be ventilated but not perfused

Planar ventilation–perfusion (VQ) scan

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How long does a DOAC take to work? [1]

Few days

How long does warfarin take to work? [1]

5 days

Which differential diagnoses are you trying to rule out on CXR with PE? [3]

Pneumothorax
Pleural effusions
Pneumonia

Sinus tachycardia

What is the rate in this ECG? [1]
Why is this calculation important? [1]

300/2.5 = 120

Because sinus: rules out afib

Why do you get sinus tachycardia in PE?

What ECGs indicate a patient is suffering from PE? [2]

Sinus tachycardia is a very common finding in PE

S1: deep S waves in S1
Q3: deep Q waves in lead 3
T3: T wave inversion in lead 3

How do you acutely treat PE in a patient who is suspected to be suffering from PE and is haemodynamically stable? [3]

Acutely:
- 15 L oxygen
- Consider 500ml saline over 15-30mins (STAT) if SBP < 90 and JVP is elevated
- apixaban or rivaroxaban (DOAC)
- LMWH is alternative

How do you acutely treat PE in a patient who is confirmed (on echocardiography or CTPA); haemodynamically unstable? [5]

Acutely:
- Thrombolysis: alteplase; streptokinase; urokinase
- Start on heparin
- apixaban or rivaroxaban
- 15 L oxygen
- Consider: noradrenaline or dobutamine: as a vasoactive drug if SBP remains < 90
- Consider: surgical embolectomy/percutaneous catheter-directed treatment if thrombolysis fails

How do you long term treat PE? [3]

Give **apixaban, rivaroxaban, edoxaban and dabigatran** for 3 months

Which patient populations would you give LMWH instead of a DOAC in a suspected PE? [1]

Use a weight-adjusted dose of LMWH in **women who are (or may be) pregnant.** **Active cancer patients**

Which groups of patients would you have longer (3-6 months) DOAC treatment for that 3months post PE? [1]

**Active cancer**: give 6 months of DOAC

What drug choice is used for long term treatment of PE in pregnant population [1] and how long for? [1]

In pregnant patients, continue **LMWH** for the **remainder** of the **pregnancy** and for at least **6 weeks postnatally** and **until at least 3 months of treatment** has been given in total

WQ16. What is the underlying pathophysiology of this condition?

**Virchow's triad:** 1.**Vessel wall damage**: - endothelial cell damage **promotes thrombus formation**, usually at the **venous valves** - Damage to the vessel wall can occur after a number of insults including **trauma, previous DVT, surgery, venous harvest, and central venous catheterisation** 2. **Venous stasis:** - poor blood flow and stasis **promote the formation of thrombi**. - Venous stasis and congestion result in **valvular damage**, further promoting thrombus formation. Increased venous stasis s associated with age >40 years, immobility, general anaesthesia, paralysis, spinal cord injury, myocardial infarction, prior stroke, varicose veins, advanced congestive heart failure, and advanced COPD. 3. **Hypercoagulability**: - Causes include **cancer**, **high-oestrogen states** (oral contraceptives, hormone replacement, obesity, pregnancy), **inflammatory bowel disease, nephrotic syndrome, sepsis, blood transfusion**, and **inherited thrombophilia** (factor V Leiden mutation, prothrombin gene mutation, protein C and S deficiency, antithrombin deficiency, and antiphospholipid antibody syndrome).

Which medications increase the liklihood of PE?

Contraceptive pills Hormone replacement therapy

Why does the combined pill increase likilihood of blood clots? [1]

Increased **oestrogen** causes **hypercoagulability**

Which patient populations are more at risk of PE? [5]

Suffer from **DVT** Recent **surgery** Significant **immobility** **Pregnant** women Active **cancer** Recent **MI** **Antiphospholipid** **antibody** **syndrome** Recent **trauma**

The leading cause of death in patients with high-risk (massive) PE is acute [1]

The leading cause of death in patients with high-risk (massive) PE is **acute right ventricular (RV) failure with resulting hypotension**

Explain what ABG would present like for a PE patient? [3]

Patients with a pulmonary embolism often have **respiratory** **alkalosis** on an ABG. **Hypoxia** causes a **raised respiratory rate.** Breathing fast means they **“blow off” extra CO2**. A **low** **CO2** means the blood becomes **alkalotic**.

Name differential diagnosis to PE that would cause respiratory alkalosis [1] How would you distinguish between the two? [1]

The other main cause of respiratory alkalosis is **hyperventilation syndrome** - Patients with **PE** will have a **low pO2** - Patients with **hyperventilation** **syndrome** will have a **high pO2.**

Why does BP fall in PE ? [1]

Causes obstructive shock

What is the MoA of warfarin? [1] What is the INR targer for warfarin when treating DVTs and PEs? [1]

Warfarin is a **vitamin K antagonist.** The target **INR** for warfarin is between **2 and 3** when treating DVTs and PEs.

What pathology would contraindicate anti-embolic compression stockings for PE / VTE [1]

Anti-embolic compression stockings are also used unless contraindicated (e.g., **peripheral arterial disease)**.

Why would CTPA be contraindicated when investigating PE? [1]

Kidney damage; contrast toxicity