PE Flashcards
What further investigations are required in a patient with an unprovoked DVT or PE ?
History
FBC, Renal, liver, PT, aPTT.
Examination.
Do not investigate for cancer and less relevant symptoms or signs. 
What is the simplified PESI score?
Age > 80
Cancer (diagnosed within last 12 months or undergoing treatment).
Chronic cardiopulmonary disease.
Heart rate >=110
Systolic BP<100
SATS <90
All worth 1 – low-risk =0, 1+ = high
What is the 30 day mortality of a patient with a low risk sPESI score?
1%
sPESI score ≥1 = 30 day mortality of 11%
What are the Hestia criteria?
Contraindications for OP PE management
Haemodynamic instability
Need for thrombolyses or embolectomy
Active bleeding or high risk of bleeding
>24 hours of oxygen to keep sats >90%
PE on anticoagulation.
Severe pain needing IV meds >24 hours.
Medical or social reason for hospital treatment >24hrs
CrCl <30
Severe liver impairment.
Pregnancy
History of heparin induced thrombocytopenia.
When can and patient with a confirmed PE be managed as an outpatient?
sPESI 0
No exclusion criteria.
No specific assessment of bleeding risk is required in patients deemed low risk by risk stratification.
Measurement of RV: LV, ratio on CT or RV on echo is not required in low risk patients.
If RV dilation identified in patient, otherwise suitable for outpatient management, consider using BNP, Troponins I/S - if normal, then can be outpatient (consider alternative causes for trop rise)
What further assessment should be carried out in a patient with PE considered low risk on sPESI?
Check for exclusion criteria for outpatient management.
Do not need specific assessment of bleeding risk or assessment of RV function.
How should a patient with suspected PE be managed?
Investigation on the same day if feasible. Otherwise anticoagulation followed by outpatient imaging within 24 hours if deemed low risk
How should patients with confirmed PE being treated as an outpatient be managed?
One of:
LMWH + dabigatran
LMWH + edoxaban
Apixaban (single agent)
Rivaroxaban (single agent)
Single agent options preferred
Verbal and written information on the signs and symptoms of recurrence, major bleeding and complications.
Formal review at least once during the first week.
Mr B has been admitted to hospital with a PE. His sPESI score was 1 on arrival but is now 0. What should happen next?
Can be discharged - requires consultant review (or ST3 if not available) prior to discharge
Mr B attends hospital with pleuritic chest pain and breathlessness. He had a hip operation in the last two weeks. He has no other past medical history. His observations are within the normal range. What is the next most appropriate step?
CTPA or interim anticoagulation while waiting CTPA
2 level Wells score:
3 clinical signs and symptoms of DVT.
3 alternative diagnosis less likely than PE
1.5 heart rate >100
1.5 immobilisation >3 days or surgery within 4 weeks
1.5 previous DVT or PE
1 haemoptysis
1 malignancy (treatment within the last 6 months or palliative)
If >4 then CTPA (or anticoagulation to bridge to CTPA)
If <=4 then d-dimer (give anticoagulation if wait >4hrs for result)
If d-dimer positive then CTPA/anticoagulation while waiting for CTPA
NB. if CTPA then negative consider leg ultrasound for DVT if suspect
What makes up the Wells score for PE
2 level Wells score:
3 clinical signs and symptoms of DVT.
3 alternative diagnosis less likely than PE
1.5 heart rate >100
1.5 immobilisation >3 days or surgery within 4 weeks
1.5 previous DVT/PE
1 haemoptysis
1 malignancy (treatment within the last 6 months or palliative)
If >4 then CTPA (or anticoagulation to bridge to CTPA)
If <=4 then d-dimer (give anticoagulation if wait >4hrs for result)
Mr X has a CTPA showing a PE. What further investigation should be carried out?
Bloods: FBC, Renal, liver, PT, aPTT
History and examination.
No need for cancer investigations, unless suspected from above.
If low risk as per sPESI, then no need for echo.
Mr Z has a PE confirmed on CTPA. He has no other medical history and is low risk on stratification. How should he be treated?
Apixaban or Rivaroxaban single-agent
Otherwise LMWH for 5d with Dabigatran or Erdoxaban
Or LMWH with Warfarin until INR >2 on consecutive readings
How should PE be managed in a patient with renal failure creatinine clearance less than 15?
LMWH or UFH
Can consider warfarin with above as bridge
Nb. CrCl 15-50: as per no renal impairment
Apixaban or Rivaroxaban single-agent
Otherwise LMWH for 5d with Dabigatran or Erdoxaban
Or LMWH with Warfarin until INR >2 on consecutive readings
How should a patient with confirmed PE and active cancer (receiving treatment, diagnosed within six months, recurrent, metastatic, or inoperable) be treated?
Consider DOAC
LMWH or warfarin with LMWH bridge if unsuitable
Treat for 3 to 6 months
How should a patient with antiphospholipid syndrome and a PE be treated?
Warfarin with LMWH bridge
How long should a patient with a PE be treated for if unprovoked?
Assess at three months.
NB for cancer this is 3 to 6 months
Mr Z presents the hospital with chest, pain, breathlessness, and haemoptysis. What is the next most appropriate step?
History, examination and CXR
If likelihood of PE considered by doctor <15% use the PERC criteria to decide about further work up.
PERC CRITERIA all worth 1 (if any positive then can’t use to rule out PE). If all negative then PE<2%
Age >= 50
HR >= 100
SATS < 95
Unilateral leg swelling.
Haemoptysis
Surgery or trauma <= 4 weeks
Prior PE or DVT?
Oral contraceptive/hormone replacement.
What are the PERC criteria?
PERC CRITERIA all worth 1 (if any positive then can’t use to rule out PE). If all negative then PE<2%
Age >= 50
HR >= 100
SATS < 95
Unilateral leg swelling.
Haemoptysis
Surgery or trauma <= 4 weeks
Prior PE or DVT?
Mr T has signs and symptoms of both a DVT and PE.
What initial diagnostic investigation should be carried out?
Can be for either DVT or PE
Should you wait for results of blood tests before starting treatment for a patient with confirmed PE?
No, but need to review within 24 hours
How should a patient with PE and haemodynamic instability be managed?
UFH infusion and consider thrombolysis
Do not offer if RV dysfunction without haemodynamic instability
Mr B has a PE. What is it very high risk of bleeding. How should he be managed?
IVC FILTER
Also, consider if failure of anticoagulation.
Must have strategy in place for removal.
When should thrombophilia testing be considered in a patient with PE?
If unprovoked should consider antiphospholipid antibodies.
In unprovoked also consider hereditary thrombophilia screening if first-degree relative with DVT or PE
Jane is pregnant. She presents to the ED with chest pain and breathlessness. She has no calf swelling. observations are normal. chest. X-ray shows slight opacification in the right lower zone. What is the next appropriate investigation?
CTPA
- if suspicion of DVT than Doppler would be performed first
- Otherwise, CTPA or VQ. If abnormality on CXR then CTPA preferred
Nb. VQ scan has slightly higher risk of childhood cancer, but slightly lower risk of maternal breast cancer always should be discussed with the woman.
What is risk of recurrence of VTE in pt with unprovoked VTE after stopping anticoagulant?
10% first year then 5% every year after
What proportion of patients with PE develop CTEPH?
3.8% over 10 years
How should pt with PE who is 130kg be managed?
Anticoag but with therapeutic level monitoring (do for <50kg or >120kg)
Pt with PE has CrCl of 20ml/min. How should he be managed?
For CrCl 15-50
Apixaban or rivaroxaban
Or LMWH for at least 5 days followed by: edoxaban or dabigatran if estimated creatinine clearance is 30 ml/min or above
Or LMWH or UFH, given concurrently with a VKA for at least 5 days or until the INR is at least 2.0 in 2 consecutive readings, followed by a VKA on its own.
How should pt with CrCl 12 with PE be managed?
For CrCl <15:
LMWH
or
UFH
or
LMWH or UFH concurrently with a VKA for at least 5 days or until the INR is at least 2.0 in 2 consecutive readings, followed by a VKA on its own.
When should PE undergo thrombolysis?
Haemodynamic instability
- BP<90 or drop ≥40 for 15mins
- BP<90 + end-organ hypoperfusion (e.g. elevated lactate, confusion, anuria)
Consider if marked dyspnoea, hypoxaemia, elevated trop, RV dysfunction on echo, RV enlargement on echo/CT, free-floating t thrombus
What are CIs to thrombolysis for PE?
Absolute
- History of haemorrhagic stroke
- Active brain malignancy
- Brain surgery/trauma <2months
- Internal bleeding <6months
Relative
- Bleeding diathesis
- Uncontrolled HTN (220/110)
- Non-haemorrhagic stroke <2months
- Surgery <10days
- Plt <100
How should pt with intermediate-high risk of PE be managed?
In hospital with LMWH over 2-3 days to ensure remain stable before switching to oral
How and how long should pregnant pt with PE be treated?
LMWH until 6 weeks post-natal or 3 months total (whichever is longer)
