Haemoptysis & Pulmonary Embolism Flashcards
3 things virchow’s triad precursors to THROMBUS formation?
- Stasis (of blood)
- Vascular damage
- Probs with constituents (eg Thrombophillia)
32y/o female, on OCP, just got off flight from australia, complaining of 1/7 SOB, Pleuritic chest pain, Dull ache in swollen calf, feverish - diagnosis?
Pulmonary embolism
PE = v diff to diagnose but what would be some “cardinal” signs?
Pleuritic chest pain SOB Fever Haemoptysis Signs of R hrt strain - s1, q3, t3 on ECG & raised pulmonary pressure (JVP raised?)
4 haematological disorders that could contribute to thrombus formation
Factor V Leiden
Prothrombin mutation
Protein C, S deficiency
Antithrombin deficiency
With what 4 possible conditions might a “paradoxical embolus” cross from the right heart to the left hear & systemic circulation?
Patent ductus arteriosus
Patent foramen ovale
Atrial septal defect
Ventricular septal defect
What finding on auscultation might indicate a patent foramen ovale?
Continuous “machine-like” murmur
Why is injury to the bronchial circulation so catastrophic in causing haemoptysis?
It is systemic - comes straight off the aorta so v high pressure and can be fatal loss of blood.
PE diagnosed in an IV drug user - likely source of their thrombus?
Infected thrombus formation from injection
Infective endocarditis patient has PE - source of thrombus?
Vegetation from valve dislodged
Give at least 3 diff diagnosis for a swollen painful leg other than DVT
Cellulitis Ruptured bakers cyst Oedema Superficial thrombophlebitis Haematoma
List some major risk factors for PE / DVT
Elective Surgery Immobility OCP MI /Heart failure Fracture Nephrotic syndrome Smoking Genetic
Other than clot embolus, what types of embolus could occur (5 - think, fractures, scuba, cancer, birth, tropical disease)
Fat embolism (fracture) Gas (SCUBA / knife injury / removal of line) Amniotic fluid - in birth Schistosomiasis eggs in liver Tumour embolus
Sources of ARTERIAL thrombus (4)
Left atrial (AF / Mitral Stenosis)
Infected / damaged valves - endocarditis / prostheses
Atherosclerotic plaque dislodged
Aneurysm
Why might ARTERIAL / left heart thrombus cause a stroke?
Goes from L heart - aorta - carotid & lodges in brain
This condition (also possible at altitude) might increase thrombus risk
Polycythaemia (rubra vera)
Why might a young / pregnant woman opt for a ventilation perfusion scan over a CT Pulmonary Angiogram to investigate suspected PE?
CTPA much higher level of radiation - potential damage to mother / foetus and breasts.
What would be a quick effective way to diagnose suspected DVT without messing around with D Dimers and Well’s scores?
Doppler ultrasound of the leg
Initial treatment of suspected DVT while waiting for Doppler?
Sub cutaneous Low Molecular wt Heparin (Enoxaparin / Clexane) - stop when INR reaches 2.5
Longer term treatment for DVT?
Warfarin - 3 - 6 months
Three main types of PE presentation?
- Massive - fatal / life threatening - similar to MI
- Acute, smaller - symptomatic - SOB, pleuritic pain, SOB, fever
- Chronic - progression of symptoms incl rh failure, pulmonary HTN, prog SOB
As well as fever, pleuritic chest pain, SOB and haemoptysis, what other symptoms might someone have with a PE?
Syncope
Dizziness
Agitated / restless
Useful investigations in suspected PE (radiological and blood and cardiac)
- ABGs
- D-Dimer
- CXR (may be normal, may exclude other illness, may see small effusion, wedge shape, linear shadow)
- ECG -S1 Q3 T3 = Big S wave lead 1, Big Q wave lead 3, inverted t wave lead 3 = just indicates RIGHT HEART strain not nec. PE
- CT Pulmonary Angiogram - gold standard
- Ventilation / perfusion scan
Management of PE - Immediate treatment?
High Flow O2, IV fluids, Analgesia (for pleurisy)
Unfractionated heparin / Clexane / Enoxaparin
Thrombolysis - tPA if severe
Management of PE longer term?
Warfarin - 3 to 6 months, get INR 2-3
IVC filters
Novel oral anticoagulants (NOACS) - Apixaban, Rivaroxaban (factor Xa inhibitors)
Direct thrombin inhibitors (DTIs) Dabigatran
4 most common causes of streaky / small haemoptysis (think chronic)
Smokers / bronchitis
Pneumonia / TB
Bronchiectesis
Lung cancer
Most common cause of massive hameoptysis
Bronchiectesis
Lung cancer
things that look opaque on cxr
Consolidation Infarcted lung Collapse (fluid / tissues have encroached lung space) Mass (tumour) Pleural effusion
