PE Flashcards
PE
Diagnosis / Tests
I. IF => Clinical fatures
- SOB
- Pleuritic Chest Pain
- Tachypnea, Tachycardia
- Normal CXR
- Normal Physical Exam
- Wells Criteria
II. THEN => TESTS
(high risk)
- Spiral CaT scan (if negative (thrombus in lung perifery) go 2)
- Compression US Proximal veins leg (if negative 3)
- Angiogram
(low risk)
- D-Dimer & Compression US
- D-Dimer & Cat scan
PE Management
(if diagnosed)
Before therapy or any test if you have high risk patients what are you going to do?
! - Oral Anticoagulation is 6 months instead of 3
BEFORE ANY
O2
If high risk start Heparin
If confirmed start Coumadin same time with Heparin
*therapeutic INR
Warfarin side effect WARFARIN SKIN NECROSIS
Warfarin necrosis usually occurs 3 to 5 days after drug therapy is begun, and a high initial dose increases the risk of its development. Heparin-induced necrosis can develop both at sites of local injection and - when infused intravenously - in a widespread pattern.
In warfarin’s initial stages of action, inhibition of protein C and Factor VII is stronger than inhibition of the other vitamin K-dependent coagulation factors II, IX and X. This results from the fact that these proteins have different half-lives: 1.5 to six hours for factor VII and eight hours for protein C, versus one day for factor IX, two days for factor X and two to five days for factor II. The larger the initial dose of vitamin K-antagonist, the more pronounced these differences are.
This coagulation factor imbalance leads to paradoxical activation of coagulation, resulting in a hypercoagulable state and thrombosis. The blood clots interrupt the blood supply to the skin, causing necrosis. Protein C is an innate anticoagulant, and as warfarin further decreases protein C levels, it can lead to massive thrombosis with necrosis and gangrene of limbs.
PE Treatment
- Pregnancy
- Thrombolytics
- Thrombectomy
- Compression Stockings (post-phlebitic syndrome)
- Long Life AntiCoag
- Recurent Thrombosis on AntiCoag
- PREGNANCY - coumadin (teratogenic) give LMWH
- THROMBOLYTICS - only for hemodynamic unstable patient (Massive PE)
- THROMBECTOMY - only for hemodynamic unstable and throbolytic contraindication
- COMPRESSION STOCKINGS - prevent Post-Phlebitic (post-thrombotic) syndrome (patient develop chronic sweling due to DVT) [USE FOR MONTHS]
- LONG LIFE ACOAG - for patient with recurent PE
- RECURENT THROMBOSIS ON ANTICOAGLATION - (breakthrough thrombosis) => hapends usualy in patients with cancer or on heparine induced thrombocytopenia (not presenting with bleeding most of times but with recurent thrombosis on anticoag)
**PE Management **
- Heparine side effects?
- LMWH why is it prefered, and posible side effect?
- What do you do to screen heparin side effects?
- How do you manage SE?
1.
Heparin may cause thrombosis (paradoxical effect) instead of bleeding
Heparine induced thrombocytopenia **(3-5 days) or right away if sensitised => presents with bleeding go on LMWH
2.
LMWH because it is less likely to cause thrombocytopenia and is given on /kg basis (Pros) LMWH can cause Heparin-Induced Thrombocytopenia, to but on a less extent
3.
_Screen _
- Patient for recurent thrombi (leg swelling, PE signs and symptoms)
- Platlets
- STOP ALL HEPARIN WHEN PLATLETS DECREASE BY 50%
- STOP EVEN FLUSHING OF LINES WITH HEPARINE
4
switch to Argatroban
Thrombophilias (Hypercoagulable state)
Fetal loss / stillbirths
Fat Embolism
- 3-4 days after long bone factures
- Rare after CPR
- Usualy elder patient extended trauma
- Acute SOB
- Petechiae: neck and axilla
- Confusion
Rx:
- Supportive (O2, [maybe Steroids])
- NO ANTICOAGULATION
Heparin may cause thrombosis (paradoxical effect)