PE Flashcards
The increased pulmonary vascular resistance may lead to
elevation o right ventricular (RV) wall stress, dilatation, and contractile ailure, compromising cardiac output. Recurrent and chronic PE can cause remodeling
o the pulmonary vasculature with pulmonary hypertension leading to right-sided heart ailure
Clinical Presentation
- dyspnea,
- pleuritic chest pain (due to pleural irritation,worse on inspiration),
- breathlessness
-Diziness/pre-syncope -15%
hemoptysis, cough, - or syncope (due to reduced cardiac output).
-Non pleuritic chest pain - 15%
Signs may include
tachypnea, tachycardia bronchospasm, and evidence of elevated pulmonary artery pressure including an accentuated pulmonic component of the second heart sound and jugular venous distention pyrexia cyanosis hypotension raised JVP Pleural rub pleural effusion Atrial fibrillation (rare)
Diagnosis
most common electrocardiographic abnormality is
sinus tachycardia; there may be evidence o RV strain (e.g., inverted T waves in leads V1–V4
or an “S1–Q3–T3” pattern: a prominent S wave in lead I, Q wave in lead III, inverted T wave
in lead III).
new onset AF,RBBB,RAD
RV strain may also produce elevated serum levels of
> cardiac-specific troponins
> or B-type natriuretic peptide (described in Chapters 7 and 9, respectively)
Arterial blood
gas analysis may show
decreased arterial oxygenation but is insensitive to the diagnosis of PE. The pre erred test to conf rm the diagnosis is computed tomographic angiography (CTA;
). For patients who cannot tolerate CTA, such as those with renal insuficiency or hypersensitivity to radioiodinated contrast agents, radionuclide ventilation–perfusion (V/Q)
lung scanning may be obtained instead but is less precise or the diagnosis. Catheter-based
pulmonary angiography is rarely necessary or conf rmation
Treatment
In patients with established PE, urgent anticoagulation is instituted to prevent recurrent embolism. Anticoagulation measures are similar to those used or DVT. In patients with proximal
DVT or established PE who cannot be treated with anticoagulants (e.g., because o a bleeding disorder), an intravascular lter can be percutaneously inserted into the in erior vena cava to prevent emboli rom reaching the lungs. Occasionally, systemic thrombolytic therapy or surgical pulmonary embolectomy is undertaken or patients with massive PE
PERC score
- Age > 50 yo
- HR >100
- SaO2 on room air <95%
- Unilateral leg swelling
- Haemoptysis
- Recent surgery or trauma
- Previous PE or DVT
- Exogenous Oestrogen - oral contraceptives,hormone resplacement or other estrogen hormones
Well’s score for PE
can stratidy patients as low or high risk.In high risk patients , you should proceed straight to imaging.In low risk consider D - dimer test
- Clinically suspected DVT - score : 3
- PE is most likely the diagnosis : 3
- Tachycardia > 100 bpm : 1.5
- Immobilisation > 3 days OR surgery - in previous 4 weeks : 1.5
- History of DVT or PE in past : 1.5
- Hemoptysis : 1
- Malignancy : 1
A D- dimer can be useful to rule out PE or DVT as a differential
Negative D-Dimer + low Well’s score = PE or DVT is extremely unlikely
Other factors that caused increased D-Dimer
liver disease high rheumatoid factor malignancy trauma pregnancy recent surgery
PE with signs of right heart strain in hemodynamically unstable patient( raised troponin,heart motion abnormalities on echo - often done at the bedside in ED)
Thrombolysis - e.g 50mg aleplase MANY CONTRAINDICATIONS
Main treatment of PE
anticoagulation
warfarin
NOAC - rivaroxaban
example of warfarin treatment
Anticoagulant with LMWH - dalteparin 200u/kg/24hrs.
The max dose is 18.000
At the same time start oral warfarin 10mg
Stop the heparin when INR >2 and continue warfarin for a minimum of 3 months,aiming for INR 2-3
It is indicated for evaluation of venous thromboembolism in a pregnant woman
V/Q scan
