PE

Question 1

Causes

Answer 1

DVTs in proximal leg or iliac veins

Rarely:

• Right ventricle post MI
• Septic emboli in right sided endocarditis

Question 2

Risk Factors (SPASMODICAL)

Answer 2

Sex: F
Pregnancy
Age: ↑
Surgery 
Malignancy
Oestrogen: OCP/HRT
DVT/PE previous Hx
Immobility
Colossal size
Antiphospholipid Abs
Lupus 
Anti-coagulant

Question 3

Symptoms

Answer 3

Acute dyspnoea
Pleuritic pain
Haemoptysis
Syncope

Tachycardia
Tachypnoea

Question 4

Signs

Answer 4

Cyanosis
Tachycardia, tachypnoea
RHF: hypotension, ↑JVP, loud P2
Evidence of cause: DVT - red, painful unilateral leg

Question 5

Ix

Answer 5

Respiratory exam 
Basic Obs 
WELLS Score 
Bloods: FBC, U+E, clotting, D-dimers, CRP
ABG
CXR
ECG: sinus tachycardia, 
Doppler USS: thigh and pelvis 
CTPA

Question 6

Diagnosis

Answer 6

1. Wells’ Score
   • Low-probability → perform D-dimers
   - Negative → excludes PE
   - Positive → CTPA

• High probability → CTPA

Question 7

Prevention

Answer 7

Risk assessment for all pts
TEDS
Prophylactic LMWH
Avoid OCP/HRT if at risk

Question 8

Mx of PE

Answer 8

1. Sit up
2. Oxygen - 94 - 98%
3. Morphine + metoclopramide
4. LMWH - enoxaparin
5. If hypotension - fluids
6. Warfarin

Question 9

Massive PE

Answer 9

Thrombolysis

• streptokinase
• alteplase

Question 10

Checks before PE treatment

Answer 10

Renal impairment

Cancer

Antiphospholipid syndrome

Haemodynamic instability

Question 11

PE treatment

Answer 11

1st line DOAC - Apixaban or rivaroxaban
(Even if undiagnosed)
Provoked PE - 3 months
Unprovoked - 6 months

Question 12

If apixaban and rivaroxaban are contraindicated

Answer 12

If allergic:
- LMWH for atleast 5 days followed by dabigatran or edoxaban

• LMWH + warfarin for atleast 5 days then warfarin alone
  (INR 2+)

Question 13

If Creatinine clearance less than 15

Answer 13

One of:
LMWH
UFH
LMWH and warfarin for atleast 5 days then warfarin alone

Question 14

If active cancer

Answer 14

DOAC

Question 15

If has antiphospholipid syndrome

Answer 15

LMWH with warfarin for 5 days then warfarin alone

Question 16

Haematological risk factors

Answer 16

Antithrombin deficiency
Protein C deficiency
Protein S deficiency
Antiphospholipid syndrome

Question 17

Wells score 4 or less

Answer 17

PE less likely

D - dimer test

Question 18

If wells score more than 4

Answer 18

CTPA

+ve - diagnose PE and continue treatment

• ve
• if DVT suspected consider proximal leg vein USS
• if not suspected, stop anticoagulants and review other diagnosis

Question 19

Pulmonary embolism rule out criteria

Answer 19

In cases where PE not suspected at all

Question 20

Huge PE

Answer 20

e.g. saddle embolism

Thrombolysis with alteplase or streptokinase

Question 21

If CTPA -ve but D-dimer +ve

Answer 21

Stop DOAC

Repeat CTPA in 1 week

Question 22

If there is renal impairment and can’t do CTPA

Answer 22

V/Q scanning

Question 23

ECG changes

Answer 23

Sinus tachycardia

Or S1Q3T3

Question 24

PE on examination

Answer 24

Normal