Clinical aspects of pulmonary embolism and hypertension Flashcards
What are the two main types of thrombo-embolic disease?
- DVT
2. Pulmonary embolism
What is PE?
Blockage of a pulmonary artery by primarily a blood clot.
Could also be air, tumour, fat.
What is pulmonary infarction?
Death of lung tissue due to inadequate perfusion
DVT’s can be proximal or distal. Which is more likely?
- Proximal- Ileo-femoral. Most likely to embolise. Can cause venous insufficiency and ulcers
- Distal- Popliteal, least likely
Clinical presentation of DVT? (4)
- Swollen
- Hot
- Red
- Tender
Can involve all of leg or calf
Differentials of DVT? (3)
- Popliteal synovial rupture
- Superficial thrombophlebitis
- Calf cellulitis
Investigations for DVT? (2)
- Ultrasound doppler leg scan
2. CT scan- ileofemoral veins, IVC, pelvis
What are the clinical presentations of PE based on size
- Small (3)
- Medium (3)
- Large (4)
- Small
- Progressive Dyspnoea
- Pulmonary hypertension
- RHF - Medium
- Pleuritic chest pain
- Dyspnoea
- Haemoptysis - Large
- Cardiovascular Shock
- low BP
- Central cyanosis
- Sudden death
What are the risk factors for DVT and PE? (5)
- Thrombophilia
- Pregnancy
- Contraceptive
- Pelvic obstruction
- Trauma
Others- surgery, malignancy, obesity, p.hypertension, immobility
Long flights and periods of immobility can cause _
DVT then PE
Main symptoms of DVT/PE? (5)
- Pleuritic Chest pain
- Breathless
- Haemoptysis
- Leg pain/swell
- Collapse
What are the clinical signs of DVT/PE? (7)
- Tachycardia
- Tachypnoea
- Fever
- Cyanosis
- Low BP
- Crackles/rub
- Pleural effusion
What are the ABG findings in DVT/PE?
Low PaO2 and SaO2 (Type 1 Respiratory failure)
Main CXR findings in DVT/PE?
Consolidation, P effusion, basal atelectasis (collapse)
What investigations are needed in DVT/PE? (6)
- ABG
- D dimers- reveals level of clotting
- CXR
- ECG- Right heart strain pattern
5 CT- pulmonary artery filling defect - Ultra sound- leg and pelvis
What preventative measures can be taken for DVT/PE/? (4)
- Post op mobilisation
- TED compression stockings (increases venous flow and pressure, reducing coagulation)
- Calf exercises
- Drugs
What are the treatment options for DVT/PE? (3)
- LMWH- Fragmin
- Warfarin
- Oral thrombin inhibitor- Dabigatran OR factor X inhibitor- Rivoroxiban.
Stop LMWH 2-3 days later when INR>2 (level of coagulation)
What is thrombolysis? In what cases of DVT/PE is it used for?
Artificially busting a clot using enzymes (tissue plasminogen factor).
Only for severe cases
Normally mean pulmonary arterial pressure is 12-20 mmHg. What would this value be in pulmonary hypertension?
> 25mmHg
What are the causes of pulmonary Venous and pulmonary Arterial hypertension?
- Venous (Left sided heart problems)
- LVSD
- Cardiomyopathy
- Mitral regurgitation/stenosis - Arterial (Right sided heart problems)
- Hypoxic (COPD, fibrosis)
- Multiple PE (Lupus, Systemic sclerosis)
- Vasculitis
- Drugs
- HIV
- Left to Right Shut
What is Cor pulmonale?
Right sided heart failure secondary to lung disorders (hypertension, PE).
Can also result in fluid retention due to hypoxia.
What are the clinical signs of pulmonary hypertension and RHF? (6)
- Central cyanosis if hypoxic
- Dependent oedema
- Raised JVP with V waves
- Tachycardia
- Pan systolic murmur
- Hepatomegaly.
What investigations are useful in pulmonary hypertension? (4)
- ECG- right ventricular strain, right axis deviation
- CXR- enlarged right atrium/ventricle
- ABG + SaO2
- CT pulmonary angiogram
What are the treatments used in pulmonary hypertension? (4)
- Treat underlying cause- eg COPD, infection
- Treat respiratory failure- Oxygen, Pulmonary Vasodilators (eg Diltiazem)
- Treat cardiac failure- diuretics
- Lung transplant
What is the drug Riociguat?
A pulmonary arterial vasodilator. Used in Chronic Pulmonary Hypertension.
Other chronic treatments
- Angioplasty , pulmonary endarterectomy
