PE Flashcards
stats
0.5-1 per 1000 per year
1-4% all pregnancies
80% of cases of PE and associated with DVT
Clinical presentation
Breathlessness
Pleuritic chest pain
Tachypnoea/tachycardia
Fever/haemoptysis may also be present - coughing up blood
May have clinical features of DVT
complications
- haemodynamic instability
- pulmonary infarcts
- chronic pulmonary hypertension
wells score
Wells 0-4 – 12% incidence of PE
Wells >4 – 37.5% incidence of PE
over 4 = likely
potential high risk PE
bolus of short-acting anticoagulant
write down the flowcarch for pe on notes ipad
should you consider thrombophillia testing for dvt or pe
no speak to haemotology if unusual
what test is used to diagnose
CT pulmonary angiography
what classifications are used to catagorise PE?
timing
clinical severity
location
timing classifications of pe
acute:
- Presentation at onset of vessel occlusion
subacute:
- Presents within days/weeks of initial event
chronic:
- Presents with complications of chronic emboli - eg features of pulmonary hypertension
clinical severity classifications of pe
non-massive: Haemodynamically stable and no evidence of right heart strain
sub-massive:
Haemodynamically stable but evidence of right heart strain on imaging (CT or echo) or biochemistry (elevated troponin)
massive:
Haemodynamically unstable:
Persistently low BP; <90mmHg or >40mmHg fall
Must be for >15 minutes
Persistent hypotension that requires inotropic support not explained by another cause
location classification of pe
segmental and subsegmental:
Lower order pulmonary vessels, unilateral or bilateral occlusion
lobar:
Right or left main pulmonary arteries, unilateral or bilateral occlusion
saddle: Embolus lodged at the bifurcation of the pulmonary arteries (3-6% of cases)
aeitiology
Any condition/state that increases the risk of clot formation
Provoked - transient or persistent risk factors
Factor usually easily removed
Typically within 3 months of event
Unprovoked - seen in 30-50% of cases. No readily identifiable risk factor for VTE
Not easily correctable
*Often preceded by DVT - unilateral swollen calf then embolises and leads to pleuritic chest pain and dyspnoea
major risk factors
DVT
Previous VTE
Active cancer
Recent surgery (e.g. within last 2-3 months)
Significant immobility (e.g. hospitalisation, bed-rest)
Lower limb trauma/fracture
Pregnancy (+ 6 weeks postpartum)
additional risk factors
Combined oral contraceptive pill
Long-distance sedentary travel (e.g. long-haul flights)
Thrombophilia
Obesity
Others
pathology
virchows triad
presentation
Often preceded by DVT (80%) - unilateral swollen calf (DVT symptomatic in 25% of those who then have PE) then embolises and leads to pleuritic chest pain and dyspnoea
New onset SOB (dyspnoea)
Pleuritic chest pain
*Difficult to diagnose as massive variability
signs
Hypoxia (sats < 94%)
Low grade fever (> 37.5º)
Tachycardia (> 100 bpm)
symtpoms
Cough
Syncope
Pleuritic chest pain
Dyspnoea (most significant symptom)
Leg pain and swelling
Haemoptysis
Dizziness
right heart failure is a direct concequence of PE - signs of this
Right Heart Failure
- Hypotension (BP < 90 mmHg or drop > 40 mmHg)
- Elevated JVP
- Tricuspid regurgitation (pansystolic murmur)
- Split second heart sound - high pulm pressure leads to delay in pulm valve closure
test if wells score >4
Straight to CTPA if not available immediately, interim anticoagulation if safe
test if wells score <4
D-dimer blood test within four hours. If positive arrange CTPA. If negative, PE excluded consider alternative diagnosis
whens D dimer preformed
wells score <4
PERC score
Assesses whether a ‘low-risk’ patient should undergo further evaluation for PE with D-dimer. If none of the eight criteria are met, D-dimer or imaging is not required
