Embolism

Question 1

explain the pathophysiology of embolism

Answer 1

impact of a thrumbus in the P.A
the origin of the embolus - dsital to the RA

Question 2

what is the sources of emboli ?

Answer 2

veins of the lower limb is the most common
rare are the veins of the upper limbs

Question 3

what are the consequenses

Question 5

what are the thrombotic material causing embolism?

Answer 5

fibrine
red blood cells
leucocites
platelets

Question 6

what non-thrombotic material that causes embolizm

Answer 6

bone marrow
air
amniotic fluid
tumoral fragments
exogenous foreign bodies
fat

Question 7

what are the major risk factors of embolizem ?

Answer 7

major surgery
major trauma
malginancies and the treatment
anterior venous thromboembolism
blood clotting disorders

Question 8

what are the minjor risk factors

Answer 8

advanged age
pregnancy and postpartum state
estrogens - oral contraceptives
postmenopausal substitution therapy
prolonged immobility
nephrotic syndrome
myeloprolifeative disorders
obesity
stroke
IBD

Question 9

explain the massive acute pulomonary embolism

Answer 9

occlusion of > 50% of pulmonary circulation
- sudden occlusion -> sudden collapse
- loss of conscioucness
- weak, rapid pulse
- low arterial pressure
- S3, S4
- col, pale skin
- central cyanosis
- jugular vein distanteion
- ventrcular fibrillation

Question 9

explain the clinical manifestations

Answer 9

massive - circulatory collapse
medium - pulmonaru insufficiency
small, multiple - pulmonary hypertension

Question 10

massive subacute pulmonary embolsim

Answer 10

• < 50 % vascular occlusion
• Severe, progressive dyspnea (over a few weeks) without cause/dyspnea when resting
• No thoracic pain
• Collapse/syncope - emboli/arithmias/low cardiac output
• Severe RHF/circulatory collapse/sudden death
• Internal jugular vein distention
• ECG - RHV (right ventricular hypertrophy)
• X-ray - pulmonary infarction
  Angiography and scintigraphy - perfusion defects

Question 11

minor acute pulmonaru embolism

Answer 11

• With infarction:
  
  • rare – double vasc. – pulmonary arterial and bronchial
  • Pleuritic pain, hemoptysis for a week or more
  • pleural fluid/friction rub
  • Fever
  • Hyperventilation
  • X-Ray – condensation/ segmentary atelectasis
  • 40% of PI have serosanguinolent/ serous pleural effusion
• Without infarction
  
  • Silent – dyspnea, fever, hyperventilation (possible)
  • X-Ray – normal
  • ECG – no value
  • Low PaO2 and PaCO2
  • Scintigraphy: ventilatory – normal; perfusion – hypoperfusion
    early angiography – useful, diagnosis in doubt

Question 12

explain well’s criterai for PE

Answer 12

Signs of DVT - 3 point
Dyspnea + normal X-ray - 3 point
heart rate > 100/min 1.5
immobilization > 3 days/surgery in prev 4 week 1.5
previous episode of PE or DVT 1.5
Hemoptysis 1
malignancy + treatmetn wothin 6 months or palliative 1

low clinical suspicion < 2
intermediary clinical suspicion 2-6
high clinical suspicion > 6

Question 13

chest X ray marks

Answer 13

normal X-ray + sudden dyspnea = PE
westermarks sign - focal oligemia
Palla’s sign – enlarged right descending pulmonary artery
Pulmonary infarction

Question 14

Scintigraphy ventilation/perfusion

Answer 14

• of high value for PE if X-Ray is normal
• corroborated with clinical probability – can establish the diagnosis or exclude PE

Question 15

Doppler ultrasonography

Answer 15

occlusions of the major veins of the lower limbs

Question 16

Venography

Answer 16

• opaque substance – veins of the lower limbs
• major venous occlusion
• Expensive

Question 17

Scintigraphy with radioactive fibrinogen (125 Iodine)

Answer 17

• IV isotope, preferrential uptake – inclusion of the radioactive fibrinogen in the fresh thrombus
• very sensitive test

Question 18

D-dimer ELISA test

Answer 18

• normal levels – exclude VTE in combination with a normal V/P ratio and normal Doppler
• abnormally high also in sepsis or malignancy – requires further testing

Question 19

Computed tomography

Answer 19

Spiral – thin 1mm slices, one breathing cycle 12-15 – thrombi in the bronchial arteries of the 5th order

Question 20

Pulmonary angiography

Answer 20

• Invasive (replaced by CT)
  
  • Certainty diagnosis – 1-2 mm emboli
  • Secondary signs:
    ○ Sudden vascular occlusion
    ○ Slow arterial filling
    Segmental oligemia

Question 21

Differential diagnosis of PE

Answer 21

MI
acute internal hemorrhage
cardiac tamponade
spontaneous pneumothorax
pneumonia, asthma atack, COPD exacerbation
advanced HF

Question 22

treatment

Answer 22

tormbolysis
heparin
low molecular heparin

Question 23

what are the complications of heparin therapy?

Answer 23

bleeding
thrombocytopnia
osteopenia

Question 24

what is the surgical treatment called?

Answer 24

embolectomy
in severe cases
hemodynamic instability

Question 25

Adjuvant treatment

Answer 25

pain relief (NSAID)
o2
dobutamine - beta-adrenergic agonist, inotropic positive action
treatment of RHF and cardiogenic shock

Question 26

treatment secondary prevention

Answer 26

• Filter on IVC (inferior vena cava)
  decreases the risk of pulmonary embolism for patients that cannot be on anticoagulants or have residual deep venous thrombosis (+/- anticoagulation)