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Respiratory medicine > L12 - Pulmonary Thromboembolism > Flashcards

L12 - Pulmonary Thromboembolism Flashcards

1
Q

Describe Virchow’s triad?

A
  1. Abnormal blood flow
  2. Abnormal blood constituents
  3. Abnormal vessel walls
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2
Q

Clinical features of DVT

A
  • Pain in calf
  • swelling
  • redness
  • engorged superficial veins
  • affected calf often warmer
  • ankle oedema
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3
Q

Horman’s sign

A

Pain in calf on dorsiflexion of foot

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4
Q

Describe ileofemoral thrombosis presentation

A

Severe pain and few physical signs apart from swelling of thigh

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5
Q

Describe acute minor pulmonary embolism presentation

A
  • Often asymptomatic
  • mild breathlessness on exertion

some pulmonary embolism causes pulmonary infarction localised sharp pleuritic pain and haemptysis.

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6
Q

Pleural friction rub

A
  • Abnormal lung sound

- caused by inflammation of the pleural layer of the lungs rubbing together.

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7
Q

What occurs in an acute massive pulmonary embolism?

A

Occurs when 40% of pulmonary circulation is suddenly obstructed.

Right ventricle dilates with marked increase in pulmonary artery systole pressure.

Patient becomes hypotensive.

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8
Q

What is D-Dimer?

A
  • FIbrin degradation product in blood.
  • A small protein fragment present in blood
  • after a clot is degraded by fibrinolysis.
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9
Q

Describe D-Dimer test?

A

D-Dimer levels elevated in patients with pulmonary embolism.

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10
Q

What investigations might be done for a suspected pulmonary embolism?

A
  1. Arterial blood gas: may indicate hypoxia with low PCO2.
  2. Isotope ventilation / perfusion VQ lung scan reveals areas of ventillator perfusion mismatching.
  3. Chest radiograph
  4. Echocardiogram
  5. ECG
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11
Q

Describe what might be seen on a chest radiograph on patient with suspected pulmonary embolism? (4)

A
  • relative absence of pulmonary blood vessel
  • wedge shaped infarct
  • raised hemidiaphragm
  • atelectasis
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12
Q

Atelectasis

A

Collapse of lung from absent gas exchange.

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13
Q

Describe what might be seen on an echocardiogram with a patient with suspected PE?

A
  • Shows contracting left ventricle
  • and dilated right ventricle.
  • thrombus may be seen in right ventricle outflow trace
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14
Q

Describe management of DVT if thrombus is above knee?

A
  1. Anticoagulation therapy
  2. Elasticated stocking - giving graduated pressure
  3. Patient started on warfarin
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15
Q

Describe management of a pulmonary embolism?

A
  1. Hypoxic patient gets high flow oxygen
  2. Anticoagulation with low molecular weight heparin LMWH
  3. Filter inserted into IVC to prevent further emboli in patient at high risk.
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16
Q

Management for acute massive pulmonary embolism

A
  • Fibrinolytic therapy

- Surgical embolectomy may be life saving.

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17
Q

How may a pulmonary embolism may lead to alveolar collapse?

A
  1. Lung tissue ventilated not perfused
    - –> produces an intrapulmonary dead space.
    - –> Results in impaired gas exchange.
  2. Non-perfused lung no longer produces surfactant.
  3. Alveolar collapse may occur + exacerbates hypoxaemia.
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18
Q

Describe the primary haemodynamic consequence of pulmonary embolism? (3)

A
  1. Reduction in cross sectional area of the pulmonary arterial bed
  2. causes increase of pulmonary arterial pressure
  3. and reduction in cardiac output.
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19
Q

Describe clinical features of patient with massive pulmonary embolism? (4)

A
  1. Severe chest pain caused by cardiac ischaemia due to lack of coronary blood flow.
  2. Patient shocked: pale and sweaty
  3. Tachypnoeic
  4. JVP raised with prominent a-wave
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20
Q

D-Dimer levels may also be elevated in…

A

Patients with

  • cancer
  • pregnant
  • elderly
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21
Q

Acute management of PE

A
  1. High flow oxygen
  2. Initial anticoagulant
    - subcutaneous low molecular weight heparin
  3. IV fluid to improve pumping of heart.
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22
Q

Define pulmonary hypertension

A

Increased blood pressure within the arteries of the lungs.

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23
Q

How might pulmonary hypertension be measured?

A

Right heart catheterisation

24
Q

Patients with pulmonary hypertension symptoms (5)

A
  • Dyspnoea (difficulty breathing)
  • Fatigue
  • Angina
  • Syncope (temporary loss of consciousness, related to blood flow)
  • abdominal distension
25
Q

Investigations for suspected pulmonary hypertension

A
  1. Blood test
  2. CXR
  3. ECG
    - right ventricular hypertrophy
    - right atrial enlargement
26
Q

How might pulmonary hypertension be managed?

A

Physical activity.

Vaccination for flu and pneumonia.

27
Q

Varicose veins treated by…

A

Injection with USS guided foam
sclerotherapy.
- medicine injected into BV causing them to shrink.

28
Q

Venous thrombosis often found…

A

Veins of leg and pelvis are common sites.

29
Q

Superficial thrombophlebitis (4)

A
  • Inflammatory condition of veins
  • due to blood clot just below surface of skin.
  • Involves saphenous vein.
  • Painful, tender, cord like structures associated redness and swelling.
30
Q

Shock

A

Medical emergency characterised by inadequate perfusion of vital organs.

Usually because of very low arterial BP.

Patients with shock have profound and inappropriate vasodilation.

31
Q

Raynaud’s disease

A
  • Inappropriate vasoconstriction of small arteries or arterioles.
  • Blanching of fingers, vasoconstriction, blueness
  • can be mild
  • severe cases may lead to gangrene of feet or legs
32
Q

Pulmonary Hypertension usually causes some regurgitation of blood from…

A

Right ventricle to right atrium

33
Q

Mechanism of action of heparin

A
  • Inhibits coagulation.
  • Activates antithrombin III.
  • Inhibits thrombin and other serine protease by binding to active site.
34
Q

Common sites of arterial thromboembolsim (4)

A
  1. Left atrium
  2. Left ventricle
  3. Carotid arteries
  4. Abdominal aorta
35
Q

2-Types of thrombus

A
  1. White thombus
    - forms in association with atherosclerotic plaque overlying endothelium. Contains large quantities of platelets.
  2. Red thrombus
    - mostly fibrin and trapped red cells
    - occurs in slow moving blood.
    - occurs in left atrium in patients with AF.
36
Q

Where do thrombi tend to form in the calf vein?

A

Calf vein sinuses behind the flaps of venous valves where the initial platelet adhesion occurs.

37
Q

Describe symptoms of large pulmonary embolism

A

Sudden onset.

  • chest pain
  • breathlessness and hypoxia
  • syncope
  • haemodynamic collapse due to acute right heart failure
38
Q

Describe symptoms of small vessel peripheral pulmonary artery occlusion (2)

A
  • pleuritic chest pain

- haemopytsis due to alveolar haemorrhage

39
Q

Triad of factors predisposed to venous thrombosis… (3)

A
  • local trauma to vessel wall
  • hypercoagubility
  • stasis of blood flow
40
Q

What is usually the immediate cause of death of PE?

A

Progressive right heart failure is then the usual immediate cause of death from PE.

41
Q

name some nonthrombotic pulmonary embolisms

A
  • Fat embolism

- Amniotic fluid embolism

42
Q

Paradoxical embolism occurs through a…

A

Through a patent foramen ovale.

43
Q

When is thrombophilia testing considered?

A

Considered for patients with unprovoked PE or PE if it is planned to stop anticoagulation treatment.

44
Q

Factor V Leiden

A

Inherited disorder of blood clotting.

  • causes resistance to activated protein C
  • protein C important role in regulating anti coagulation, inflammation and cell death.
45
Q

How might left heart disease lead to pulmonary hypertension?

A
  • Pulmonary BVs normal & undamaged
  • LHS heart unable to pump effectively
  • back up of blood into pulmonary veins and capillary beds
  • increases pressure in the pulmonary artery
46
Q

How might chronic lung disease cause hypoxic vasoconstriction?

A
  • areas of lungs diseased
  • unable to deliver oxygen to blood
  • pulmonary arterioles start to constrict
  • shuttling blood away from damaged areas of the lungs
47
Q

Widespread vasoconstriction of pulmonary arterioles will lead to …

A
  • increased pulmonary resistance
  • harder for right ventricle to pump out blood
  • RHS of heart has to generate
  • increased pressure leading to pulmonary hypertension
48
Q

Describe what occurs in chronic thromboembolic pulmonary hypertension

lots of points sorry!

A
  • recurrent blood clots of pulmonary vessels
  • clots can embolize in lungs
  • blocking pulmonary vessels
  • increasing resistance to blood flow
  • causes endothelial cells to release histamine and serotonin
  • this constricts pulmonary arterioles
  • decreases release of NO and prostacyclin (which would’ve dilated arterioles)
  • blockage and narrowing leads to rise in pulmonary BP
49
Q

What will be released by damaged endothelial cells lining the pulmonary arteries?

A
  • endothelin-1
  • serotonin
  • thromboxane

Pulmonary arteriole constriction
Hypertrophy of smooth muscle

50
Q

State a consequence of pulmonary hypertension in lungs

A

Pulmonary oedema

- excess fluid in the pulmonary interstitium

51
Q

Consequences of pulmonary hypertension in heart leading to cor pulmonae

A
  • harder for right ventricle to pump blood
  • RV hypertrophy
  • muscles of RV get very bulky
  • their oxygen demand will outweigh their oxygen supply
  • causing RHS heart failure
  • known as cor pulmonae
52
Q

Consequences of blood backing up into venous system as a result of PH (3)

A
  • increase in JVP
  • fluid build up in liver causing hepatomegaly
  • leg oedema
53
Q

Example of symptom that might occur in LHS heart failure

A

Orthopnea - shortness of breath that is worse when lying flat

  • lying flat pulls more blood from veins into the heart
  • extra blood increases hydrostatic pressure in pulmonary capillaries
54
Q

Primary pulmonary hypertension

A

BV in lungs narrow and constrict —> leading to PH

AKA: idiopathic pulmonary arterial hypertension

55
Q

Secondary pulmonary hypertension

A

Adverse outcome of a variety of systemic disorders

56
Q

Pulmonary arterial hypertension

A
  • increased pulmonary vascular resistance
  • hyperplasia and hypertrophy of arterial vasculature
  • disorganised endothelial cell proliferation
  • decreased production of vasodilators (prostacyclin and nitric oxide)
  • overexpression of vasoconstrictors such as endothelin

Respiratory medicine (16 decks)

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