PE

Question 1

what is a pulmonary embolism

Answer 1

obstruction of pulmonary artery secondary to blood clot

Question 2

what is a thromboembolis

Answer 2

a blood clot on the move

Question 3

what is Venous thromboembolic disease (VTE)

Answer 3

2 manifestations of the same disease

Question 4

how do PEs cause ventilation perfusion mismatch (V/Q mismatch)?

Answer 4

blood cannot get to the lungs to pick up oxygen, so the alveoli has fresh air that isnt reaching the blood

Question 4

how do PEs cause ventilation perfusion mismatch (V/Q mismatch)?

Answer 4

blood cannot get to the lungs to pick up oxygen, so the alveoli has fresh air that isnt reaching the blood

Question 5

physiologic response to V/Q mismatch

Answer 5

hyperventilation which causes respiratory alkalosis

Question 6

possible consequence of thromboembolus in ASD

Answer 6

• it bypasses the RV and goes to the L side into aorta and into brain causing an embolic stroke

Question 7

phrase to describe factors that lead to DVT/PEs

Answer 7

virchows triad

Question 8

Virchows triad

Answer 8

• Intimal damage/endothelial injury
• hemodynamic changes/stasis
• hypercoagulability (cancer, factor deficiency, pregnancy, etc)

Question 9

pulmonary vasculature occlusion results in ____ and subsequent ____

Answer 9

results in hypoxemia and subsequent pulmonary vasoconstriction

Question 9

pulmonary vasculature occlusion results in ____ and subsequent ____

Answer 9

results in hypoxemia and subsequent pulmonary vasoconstriction

Question 10

what is the classic triad of PEs that is rare

Answer 10

sudden dyspnea
pleuritic chest pain
hemoptysis

Question 11

most common sign of PE on physical exam

Answer 11

tachypnea

Question 12

lung exam with PE

Answer 12

usually normal but rales may be heard

Question 13

sx of DVT

Answer 13

calf or thigh pain, redness, tenderness or swelling

Question 14

3 common signs of PE on physical exam

Answer 14

tachypnea
tachycardia
low grade fever

Question 15

what is D-dimer? when is it used?

Answer 15

• product of fibrin degradation after clot is broken down
• used to exclude PE in when probability of PE is low (negative result r/o thrombosis)

Question 16

what happens if d-dimer is positive?

Answer 16

get a chest scan

Question 17

classic finding of PE on an EKG

Answer 17

S1Q3T3

wide deep S in Lead I, Q wave and T wave inversion in Lead III

seen in less than 20% of PEs

Question 18

test that is useful in patients who cannot have contrast or radiation exposure (pregnancy)

Answer 18

V/Q scans

Question 19

what was the old “gold standard” imaging for PE? which imaging is now first line diagnostic imaging

Answer 19

• Pulmonary angiography was old gold standard
• First line CT pulmonary angiography (CTPA)

Question 20

which imaging is used mostly for therapeutic intervention and pre-operative evaluation of pulmonary arteries

Answer 20

pulmonary angiography

Question 21

preferred way to determine if PE is likely is via…

Answer 21

PERC rule

Question 22

when is wells criteria typically used

Answer 22

more subtle presentation or if you can’t PERC out

Question 23

how does the PERC rule work

Answer 23

if **all** 8 things apply then there is only **1% chance of VTE** at 45 days. if ANY of the statements do NOT apply to the patient then you cannot perc out

Question 24

try to list all 8 things in PERC rule | dont need to memorize for exam but helps with knowing general PE signs.

Answer 24

* under 50 yo * HR under 100 * O2 sat over 95 * no prior DVT or PE * no trauma or surgery in past 4 wks * no hemoptysis * no exogenous estrogen * no clinical signs of DVT

Question 25

what score is considered PE unlikely via modified wells criteria & traditional wells

Answer 25

* modified is no more than 4 * traditional-- under 2 is "low", over 6 is high

Question 26

3 signs of poor prognosis

Answer 26

* RV dysfunction on US * elevated biomarkers (BNP, NT-proBNP, troponin) * shock

Question 27

who is IVC filter indicated for (2)

Answer 27

* For patient w/ **PE or DVT + high bleeding risk** * **recurrent** PE **despite anticoag**

Question 28

PE unlikely, now what should you order

Answer 28

get D-dimer

Question 29

PE unlikely + D-dimer over 500, now what?

Answer 29

get CTPA

Question 30

if CTPA is positive, what does this mean?

Answer 30

PE confirmed

Question 31

if CTPA is positive, what does this mean?

Answer 31

PE confirmed

Question 32

initial management if patient has stable PE

Answer 32

* can give O2 * start IV

Question 33

initial tx if unstable hypotension & if resp. support needed

Answer 33

* Hypotension: IV fluids < 1 L & early pressor support (NE) * Resp. support: oxygen

Question 34

anticoag preferred in pregnancy or malignancy or liver dz

Answer 34

LMWH (enoxaparin) 1-2x daily SQ

Question 35

oral anticoag option

Answer 35

factor Xa inhibitors (rivaroxaban or apixaban)

Question 36

anticoag used if unstable, severe renal failure (CrCl under 30), extensive clot burden, obesity or edema

Answer 36

IV UFH

Question 37

what is the aPTT target with IV UFH

Answer 37

1.5-2.5

Question 38

4 anticoags for if there is hx of /e/o HIT

Answer 38

fondaparinux agatroban danaparoid bilvalirudin

Question 39

if there is very large PE or very unstable pt, expert consult with possiblity for what 3 interventions?

Answer 39

* thrombolytic therapy-- alteplase * catheter directed thrombus removal * embolectomy

Question 40

the last ditch effort in treating PE requires expert consultation to consider what?

Answer 40

ECMO (extracorporeal membrane oxygenation)

Question 41

typical long term anticoags (5)

Answer 41

* factor Xa in. (rivaro- or apixaban) * direct thrombin inhibitors (dabigatran)-- needs heparin at start * warfarn * enoxaparin (LMWH) * fondaparinux (subQ factor Xa inhibitor)

Question 41

typical long term anticoags (5)

Answer 41

* factor Xa in. (rivaro- or apixaban) * direct thrombin inhibitors (dabigatran)-- needs heparin at start * warfarn * enoxaparin (LMWH) * fondaparinux (subQ factor Xa inhibitor)

Question 42

typically we transition enoxaparin or IV UFH to what 3 meds (except in pregnancy)

Answer 42

* warfarin * xa inhibitor (rivaro or apixaban) * direct thrombin inhibitor (dabigatran)