PE Flashcards
How is haemodynamic instability defined in PE?
Systolic BP <90 or requiring vasopressors to maintain BP >90 despite adequate filling
AND
Evidence of end organ hypoperfusion e.g cold/clammy, increased confusion, raised lactate, oliguria/anuria
What is the usual radiation dose of a CTPA?
3-10 mSv. Can be a cause of significant radiation to the breast tissue of young females
What are the components of the simplified PESI score?
When is it used?
Age (>80)
Cancer
Chronic Cardiopulmonary disease
HR >=110
Systolic BP <100
Oxygen Sats <90
Used to identify low risk patients safe for discharge. Score of 0 is low risk
How can PE be classified in terms of risk of early (in -hospital or 30 day) death?
High risk- Haemodynamic instability, RV dysfunction on TTE or CTPA, Raised troponin, Raised PESI/clinical parameters
Intermediate high risk- Haemodynamic stability, Raised PESI score/high risk clinically, Raised Troponin AND RV dysfunction on ECHO/CTPA
Intermediate low risk- Haemodynamic stability, Raised PESI/High clinical risk, 1 or 0 of Raised troponin/RV dysfunction on ECHO/CTAP
Low Risk- Haemodynamic stability, PESI low risk, no raised trop or evidence of RV dysfunction
When is the use of unfractionated heparin recommended in the treatment of acute PE?
If there is overt haemodynamic instability (where primary reperfusion therapy is likely to be indicated) or likely imminent decompensation
In patients with severe renal impairment (with creatinine clearance <30) or severe obesity.
Which agents can be used for thrombolysis?
Alteplase, streptokinase, urokinase.
Recombinant TPA is preferable and is usually given as an accelerated dose rather than the sustained infusions with streptokinase/urokinase.
Often alteplase 100mg over 2h or 0.6mg/kg over 15 minutes (max dose 50mg).
Can give unfractionated heparin alongside alteplase but not with streptokinase or urokinase.
When are NOACs not recommended in patients with PE?
Severe renal impairment, during pregnancy and lactation or in patients with antiphospholipid syndrome
Vitamin K antagonists are recommended in patients with antiphospholipid syndrome
When should anticoagulation be discontinued for a patient with a provoked PE (major transient/reversible risk factor)?
Should be reviewed and discontinued at 3 months if appropriate
Which patients should have definite lifelong anticoagulation after PE?
Antiphospholipid syndrome (Vit K antagonists)
Recurrent VTE in the absence of a major reversible risk factort
At what point should the dose of DOACs be reviewed or adjusted in lifelong VTE treatment?
In patients WITHOUT CANCER, the dose should be reviewed after 6 months and reduced to 2.5mg BD with apixaban or 10mg OD in rivaroxaban
What are the absolute and relative contraindications to thrombolysis?
ABSOLUTE:
Prev haemorrhagic/unknown stroke
Ischaemic stroke in the past 6 months
CNS Neoplasm
Major trauma, surgery or head injury in the past 3 WEEKS
Active bleeding
Bleeding Diathesis
RELATIVE:
Pregnancy or first week post partum
PO anticoagulation
TIA in past 6 MONTHS
Refractory HTN >180
Advanced liver diseased
Active peptic ulcer
Traumatic resuscitation/non compressible puncture sites
Infective endocarditis
What pharmacological agents can be used to support in high risk PE?
Noradrenaline +/- dobutamine
Noradrenaline increased RV inotropy and systemic BP, restores coronary perfusion gradient. However systemic vasoconstriction may reduce tissue perfusion
Dobutamine increases RV inotropy and lowers filling pressures but may cause hypotension if not used with vasopressors.
What is the treatment of choice for PE in patients with active cancer?
LMWH is first line
Rivaroxaban or Edoxaban can be considered as alternative agents in patients that do not have GASTRIC CANCER
Anticoagulation should be considered for an extended period (usually lifelong) until the cancer is cured
What is the treatment of choice for PE in pregnancy?
LMWH.
NOAC not recommended in pregnancy or lactation.
Should not have epidural within 12h of LMWH dose or give LMWH within 4 hours of removal
For how long should a pregnant lady be treated for PE?
What is the treatment agent of choice?
Should be treated for at least 3 months and until at least 6 WEEKS POSTNATALLY, whichever is longer.
Treatment should ideally be with LMWH as cannot use NOACs in pregnancy/breastfeeding.
