FN: Pulmonary embolism

Question 1

Causes

Answer 1

1. Usually arise form DVTs in proximal leg or iliac veins

2. Rarely:ventricle post MI or septic emboli in right sided endocarditis

Question 2

Risk factors

Answer 2

SPASMODICAL

1. Sex: F
2. Pregnancy
3. Age: old
4. Surgery (classically 10d post-op straining at stool)
5. Malignancy
6. OestrogenL OCP/HRT
7. DVT/PE previous Hx
8. Immobility
9. Colossal size
10. Antiphoppholipid Abs
11. Lupus Anti-coagulant

Question 3

Presentation depends on

Answer 3

Symptoms and signs depends on zixe, number and distribution of emboli

Question 4

Symptoms

Answer 4

Dyspnoea
Pleuritic pain
Haemoptysis
Syncope

Question 5

Signs

Answer 5

1. Fever
2. cyanosis
3. Tachycardia, tachypneoa
   RHF: hypotension, raised JVP, loud P2
4. Evidence of cause: DVT

Question 6

Investigations

Answer 6

1. Bloods: FBC, U + E, clotting, Ddimers
2. ABG: normal or reduced Pao2 and reduced PaCO2, alkalotic
3. CXR: normal o oligaemia, linear atelectasis (wedge shape)
   ECG: sinus tachy, RBBB, right ventricular strain (inverted T in V1-V4)

Question 7

Diagnosis

Answer 7

1. Assess probably using wells score
2. Low-probability –> perform D-dimers
3. high probability: CTPA

Question 8

D-dimers explain

Answer 8

Used in low probablitity
- Negative –> excludes PE
Positive –> CTPA

Question 9

-ve Ddimer

Answer 9

has a 95% NPV for PE

Question 10

Prevention

Answer 10

Risk assessment for all patients
TEDS
Prophylactic LMWH
Avoid OCP/HRT if @ risk

Question 11

Management

Answer 11

1. Oxygen - sit p, 100% oxygen via non-rebreather mask
2. Analgesia
3. If massive consider thrombolysis (ateplase 50mg bolus stat or surgical o interventionl embolectomy
4. LMWH Heparin - enoxaparin 1.5 mg/kg
5. SBP - consider colloid or start warfarin
6. Inotropes if BP still low
7. On going management

Question 12

On going management for PE

Answer 12

1. TEDS in hospital
2. Graduated compression stockings for 2 yrs if DVT: prevent post-phlebitic syndrome
3. Continue LMWH until INR >2
4. Target INR = 2-3
5. Duration depending on cause
6. VC filter if repeat DVT/PE despite anticoagulation