Condition- Pulmonary Embolism Flashcards

1
Q

What is a pulmonary embolism?

A

Occlusion of pulmonary vessels, most commonly by a thrombus that has travelled to the pulmonary vascular system from another site

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2
Q

What is the main cause of pulmonary obstruction in pulmonary embolism and where does it tend to originate from?

A

Thrombus

  • 95% arise from DVT in the lower limbs
  • Rarely arises in the right atrium (in AF patients)
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3
Q

List some of the other causes of embolus in pulmonary embolism…

A
  • Amniotic fluid
  • Air
  • Fat
  • Tumour
  • Mycotic
  • Parasites
  • Right ventricular thrombus (post MI)
  • Septic emboli (right sided endocarditis)
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4
Q

List some risk factors for developing a pulmonary embolism…

A
  • Surgical Patients
  • Immobility- long haul flights, recent hospitalisation
  • Malignancy
  • Obesity
  • Pregnancy
  • Heart Failure
  • OCP
  • Thrombophilia
  • Previous PE
  • Genetic diseases: Factor V Leiden, Protein C/S deficiency, thrombophilia
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5
Q

The severity of the presentation of a patient with PE depends on the ………….. and ……….. of the embolus

A

The severity of the presentation of a patient with PE depends on the SITE and SIZE of the embolus

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6
Q

List the symptoms experienced by someone with a pulmonary embolism

A
  • Pleuritic Chest pain- pain exacerbated by deep breathing, coughing, sneezing, or laughing
  • SOB
  • Cough
  • Haemoptysis
  • (signs of DVT- unilateral swelling of calf)
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7
Q

Describe the presentation of someone with a large or proximal embolus…

A

If Large or Proximal Embolus:

  • Severe central crushing pleuritic pain
  • Feelings of apprehension (sign of shock)
  • Collapse
  • Acute right heart failure
  • Sudden DEATH
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8
Q

List some of the signs of someone with PE…

A

INSPECTION:

  • Tachypnoea

PALPATION:

  • Tachycardia

AUSCULTATION:

  • Pleural rub

FURTHER TESTS:

  • Low O2 sats
  • Hypotension
  • Pyrexia

Tends to be SUDDEN ONSET

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9
Q

List some of the signs of a Massive PE…

A
  • Cyanosis
  • Shock- hypotension, tachycardia
  • Signs of right heart strain (cor pulmonale) : raised JVP, left parasternal heave, accentuated S2 heart sound
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10
Q

What is the first assessment to carry out in someone with suspected PE?

A

WELL’S SCORE

  • PE unlikely ≤4, PE likely >4
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11
Q

Which imaging modality is first line for investigating someone with suspected PE? When would you offer this test?

A

Computed tomographic pulmoary angiography (CTPA)

  • Helps visulaise thrombus in pulmonary artery- can see partial or complete intraluminal filling defect
  • Offer if WELL’s greater than 4 or if WELL’s less than 4 but D-dimer is high
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12
Q

When might using CTPA be contra-indicated for use in investigating someone with PE. Which investigation can be performed instead? and how does it work?

A
  • Pregnant women
  • Renal failure
  • Children and adolescents

V/Q Scan (Ventilation- Perfusion Scans)

  • Identifies areas of ventilation and perfusion mismatch, which would indicate an area of infarcted lung
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13
Q

Other than Well’s Scores, CTPA and VQ scans what other investigations could be ordered to identify patient with PE

A
  • Bloods- U&Es, ABG, Coagulation, FBC , D-dimer test
  • ECG
  • CXR

To exclude other causes of chest pain

  • Doppler/ Duplex US to visualise DVT in lower limbs
  • Echocardiagraphy- to see cor pulmonale
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14
Q

What might you see on an ECG of someone with PE?

A
  • S1Q3T3 pattern – indicative of RV strain and therefore suggestive of PE.
    • a prominent S wave in lead I
    • a Q wave and inverted T wave in lead III
  • Sinus tachycardia- main finding
  • Right Axis deviation
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15
Q

What might you see on a CXR of someone with PE? and why

A

Westermark sign is a focus of hypovolaemia distal to the pulmonary artery that has been occluded by the PE. Blood cannot reach this region causing ischaemia and eventual infarction. This increases the translucency of the region. It is highly specific for PE but only occurs in an estimated 10% of cases.

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16
Q

How would you manage someone who is acutely admitted into hospital with a massive PE and shock and BP <90mmHg

A

They are haemodynamically unstable and have a risk of progressing into cardiac arrest

  1. Resuscitation:
    • O2
    • IV fluids
    • Vasoactive Agents: Adrenaline/ Noradrenaline
  2. 1st line: Thrombolysis (with altepase, streptokinase, rtPA)
  3. 2nd Line: Surgical Embolectomy if thrombolytic therapy is ineffective
  4. IVC filter
17
Q

How would you manage a patient who presents with PE but is haemodynamically stable SBP>90mmHg

A
  • Respiratory Support
  • Anti-coagulation
    • Fondaparinux/Heparin for 5 days
    • Warfarin for 3 months

TEDs & TINZ

(stockings + tinzaparin- DOAC)

18
Q

What non-medical measures could you take to prevent someone at high risk of PE actually developing PE?

A
  • Mobilise patient
  • TEDs & Tinz:
    • Compression stockings
    • Heparin Prophylaxis
19
Q

List the potential complications of PE…

A
  • DEATH
  • Pulmoary Infarction
  • Pulmoary Hypertension
  • Right Heart Failure
  • Recurrent Thromboembolic event
  • Iatrogenic- bleeding caused by treatment, heparin associated thrombocytopenia
20
Q

What is the mortality rate in patients with treated vs untreated PE?

A
  • 30% mortality in those left untreated
  • 8% mortality with treatment

Increased risk of future thromboembolic disease

21
Q

Which imaging modality is this and what can be seen?

A

Saddle embolus seen which is a large proximal embolus in the pulmonary trunk

22
Q

What tests could you offer to someone with recurrent PEs to check if there is an underlying issue?

A
  • Cancer screening
  • Genetic testing:
    • hereditary thrombophilia testing (Protein C/S deficiency, FVL)
    • antiphospholipid testing
23
Q

When administering warfarin which blood test should you conduct and within what range should this value be kept?

A

INR

2.0-3.0