PE Flashcards

1
Q

PE

Diagnosis / Tests

A

I. IF => Clinical fatures

  1. SOB
  2. Pleuritic Chest Pain
  3. Tachypnea, Tachycardia
  4. Normal CXR
  5. Normal Physical Exam
  6. Wells Criteria

II. THEN => TESTS

(high risk)

  1. Spiral CaT scan (if negative (thrombus in lung perifery) go 2)
  2. Compression US Proximal veins leg (if negative 3)
  3. Angiogram

(low risk)

  • D-Dimer & Compression US
  • D-Dimer & Cat scan
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

PE Management

(if diagnosed)

Before therapy or any test if you have high risk patients what are you going to do?

A

! - 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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Warfarin side effect WARFARIN SKIN NECROSIS

A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

PE Treatment

  1. Pregnancy
  2. Thrombolytics
  3. Thrombectomy
  4. Compression Stockings (post-phlebitic syndrome)
  5. Long Life AntiCoag
  6. Recurent Thrombosis on AntiCoag
A
  1. PREGNANCY - coumadin (teratogenic) give LMWH
  2. THROMBOLYTICS - only for hemodynamic unstable patient (Massive PE)
  3. THROMBECTOMY - only for hemodynamic unstable and throbolytic contraindication
  4. COMPRESSION STOCKINGS - prevent Post-Phlebitic (post-thrombotic) syndrome (patient develop chronic sweling due to DVT) [USE FOR MONTHS]
  5. LONG LIFE ACOAG - for patient with recurent PE
  6. 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)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

**PE Management **

  1. Heparine side effects?
  2. LMWH why is it prefered, and posible side effect?
  3. What do you do to screen heparin side effects?
  4. How do you manage SE?
A

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 _

  1. Patient for recurent thrombi (leg swelling, PE signs and symptoms)
  2. Platlets
  • STOP ALL HEPARIN WHEN PLATLETS DECREASE BY 50%
  • STOP EVEN FLUSHING OF LINES WITH HEPARINE

4

switch to Argatroban

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Thrombophilias (Hypercoagulable state)

A

Fetal loss / stillbirths

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Fat Embolism

A
  • 3-4 days after long bone factures
  • Rare after CPR
  • Usualy elder patient extended trauma
  1. Acute SOB
  2. Petechiae: neck and axilla
  3. Confusion

Rx:

  • Supportive (O2, [maybe Steroids])
  • NO ANTICOAGULATION
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q
A

Heparin may cause thrombosis (paradoxical effect)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly