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CVPR > CVPR Week 6: Pulmonary embolism > Flashcards

CVPR Week 6: Pulmonary embolism Flashcards

1
Q

Objectives

A
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2
Q

Pulmonary embolism description

A
  • usually refers to a blood clot which has migrated from the leg to the lung
  • but can also originate from the upper extremity, pelvis or the abdominal cavity
  • Also
  • embolisms of air, amniotic fluid,, tumor and fat can cause similar symptoms but are much less common
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3
Q

Pulmonary embolism prevalence

A
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4
Q

Clinical manifestations of Pulmonary embolism

7 listed

A
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5
Q

Diagnostic testing in Pulmonary embolism

6 listed

A
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6
Q

CT angiogram of pulmonary arteries description

A
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7
Q

CT angiogram of pulmonary arteries measures?

A

RV dilation and specifically

RV/LV ratio and an

RV/LV > 1 is associated with RV strain and an increased risk of death

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8
Q

RV/LV ratio

A

RV/LV > 1 is associated with RV strain and an increased risk of death

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9
Q

Positive study of CT angiogram of pulmonary arteries

A

in a positive study, filling defects are seen within the pulmonary arteries

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10
Q

What does a CT angiogram look like?

A
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11
Q

What does an RV/LV ratio > 1 look like?

A
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12
Q

Ventilation-Perfusion scanning

A
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13
Q

VQ scan AKA

A

Ventilation-Perfusion scanning

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14
Q

VQ scan mechanism

A

A nuclear medicine test where radiolabled xenon is inhaled while Technectium-99 labeled colloid is injected into the venous system

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15
Q

VQ scan for PE

A

Areas in the lung which have perfusion defects without ventilation defects suggest PE

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16
Q

VQ scan sensitivity and specificity

A

Much less specific and sensitive than the CT angiogram

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17
Q

VQ scan clinical use

A

usually reserved for patients with renal failure or to diagnose chronic PE

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18
Q

VQ test results which are non-diagnostic of PE

A

can indicate normal perfusion which essentially rules out PE

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19
Q

VQ test results suggesting PE

A

Diffusion defect is suggestive of PE

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20
Q

Multiple perfusion defects

A
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21
Q

Lower Extremity Doppler for DVT

A
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22
Q

Case: Does this patient have risk factors for PE?

A
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23
Q

Classic risk factors for PE

3 listed

A

Virchow’s Triad

  1. Hypercoaguability
  2. Stasis
  3. Endothelial damage
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24
Q

Risk factors for PE

A
  • Factor V ledien
  • Prothrombin gene mutations
  • Protein C and S deficiencies
  • Antithrombin III deficiencies
  • Cancer
  • Surgeries (Particularly orthopedic)
  • Neurosurgeries
  • Pregnancy
  • immobilization
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25
Q

Question

What diagnostic test for this patient?

A

in this case VQ scan because of the renal insufficiency!!

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26
Q

why not a D-dimer?

A
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27
Q

What is a D-dimer?

A

a quantitative measure of degraded crosslinked fibrin in the blood associated with blood clot formation

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28
Q

Why isn’t D-dimer very diagnostic of PE?

A
  • Because it can be elevated in patients post-surgery, pneumonia, CHF, cirrhosis, cancer and HIV
  • also it is not recommended in hospitalized patients
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29
Q

How can a D-dimer be used for PE?

A

In patients with a low to moderate suspicion of PE d-dimer has a negative predictive value of 98%

30
Q

D-dimer for high clinical suspicion of PE

A

negative predictive value is only 70%

31
Q

How to determine the probability of PE

A
  • Modified Well’s Criteria
  • Geneva Scoring System
32
Q

Clinical predictions for PE

A
33
Q

Modified Well’s Score

A
34
Q

Case Modified Wells Score

A
35
Q

Geneva scoring system for PE

A
36
Q

Case

VQ scan

A
37
Q

Case

How do we treat our patient?

A
38
Q

Patient suddenly deteriorates

How do we treat his shock?

A
39
Q

Treatment of massive pulmonary embolism: patients in shock

A
40
Q

TPA AKA

A

Tissue Plasminogen activator (T-PA)

41
Q

EKOS Catheter AKA

A

Catheter-directed thrombolysis

42
Q

ECMO AKA

A

Extracorporeal membrane oxygenation

43
Q

ECMO for PE

A

May be an option for patients who are severely unstable

44
Q

Treatment option for PE for patients who are severely unstable

A

ECMO

45
Q

EKOS catheter clinical use

A

can be useful particularly in patients with high-risk of bleeding

46
Q

PE treatment for patients who are at a high-risk for bleeding

A

EKOS

47
Q

Massive PE treatment for patients in shock

A

Thrombolytics (tissue plasminogen activator (T-PA) is the standard of care

48
Q

Patient improves but returns a week later with hematemesis

A
49
Q

Inferior vena caval filters clinical use

A
  • Lower extremity DVT or PE in patients with contraindications to anticoagulation
  • Patients with PE who have a recurrence while on anticoagulation
  • certain patients with severe pHTN and PE
50
Q

Inferior vena caval filters

A
51
Q

Long-term anticoagulation options for PE

5 listed

A
  • Warfarin
  • Low molecular weight heparin
  • Oral factor Xa inhibitors
  • Direct thrombin initiator (dabigatran)
  • Direct oral anticoagulants
52
Q

Warfarin AKA

A

Coumadin

53
Q

Warfarin considerations for PE

A
  • needs monitoring and is somewhat difficult to control
  • easily reversible
54
Q

Low molecular weight heparin considerations for PE

A

Particularly in cancer patients

55
Q

Oral factor Xa inhibitors for PE

A

Rivaroxaban or apixaban

56
Q

Direct thrombin inhibitor for PE

A

Dabigatran

57
Q

Dabigatran is a?

A

Direct thrombin inhibitor

58
Q

Rivaroxaban or apixaban are?

A

Oral factor Xa inhibitors

59
Q

Symptoms of PE

A

Symptoms of PE are somewhat non-specific

a high-index of suspicion is needed to make the Dx

60
Q

Preferred diagnostic method for PE

A

CT Angiogram

it may also provide other clues/causes to the patient’s symptoms

61
Q

VQ scan and venous dopplers are reserved for patients with?

A

contraindications to CT scan such as renal insufficiency

62
Q

contraindications to CT angiogram

A

renal insufficiency

63
Q

PE diagnosis with renal insufficiency or contraindications to CT scan

A

VQ scan and venous dopplers

64
Q

How is d-dimer used for PE?

A

useful only in patients with low clinical suspicion to rule out

65
Q

PE Treatment first-line therapies

A
  • low molecular weight heparin
  • oral factor Xa inhibitors
  • IV unfractionated heparin
66
Q

Treatment of PE in shock

A

Thrombolytics (tissue plasminogen activator-TPA) are reserved for patients in shock

67
Q

TPA for treating PE

A

Reserved for patients in shock

68
Q

Warfarin MOA

A

Vitamin K antagonist

69
Q

Long-term treatment options for PE

A
  • Warfarin
  • Factor Xa inhibitors
  • Direct thrombin inhibitors
70
Q

Direct oral anticoagulant reversibility?

A

Direct oral anticoagulants are not readily reversible

CVPR (93 decks)

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