PE

Question 1

What other rarer causes can occur?

Answer 1

Right ventricular thrombus (post MI)
Septic emboli (infective endocarditis)
Fat, air, amniotic fluid, neoplasticism cells, parasites

Question 2

Name 5 risk factors for PE?

Answer 2

Recent surgery
Thrombophilia
Fracture
Bed bound/immobile
Malignancy 
Pregnancy
Past thrombotic event eg PE

Question 3

Symptoms of PE?

Answer 3

Acute breathlessness, pleuritic chest pain, haemoptysis, dizziness, syncope

Question 4

Signs of PE include?

Answer 4

Pyrexia, cyanosis, tachypnoea, tachycardia, hypotension, raised JVP, pleural rub, pleural effusion, any signs of DVT

Question 5

What investigations would you do?

Answer 5

U+Es, FBCs, clotting screen, D-dimer, ECG, CXR, ABG, CTPA (CT pulmonary angiography)

Question 6

What might you see on a ECG?

Answer 6

Normal, sinus tachy, RBBB, AF, Q and inverted T waves in lead III, deep S wave in lead I

Question 7

CXR will often show what features?

Answer 7

Often normal, decreased vascular markings, small pleural effusion, wedge shaped are of lung infarction, atelectasis (complete or partial collapse of the lung)

Question 8

ABG will show what?

Answer 8

Picture of hyperventilation and poor gas exchange; low O2, low CO2 and often low pH

Question 9

What is the advantage of conducting a D-dimer test?

Answer 9

It has very high sensitivity but very low specificity, this holds the advantage that if someone gets a normal D-dimer it can exclude a PE

Question 10

What is the advantage of conducting CTPA?

Answer 10

Highly sensitive and specific

Question 11

What scan might you do to aid diagnosis if CTPA unavailable?

Answer 11

V/Q scan

Question 12

What is the first step of management, as with any acute presentation?

Answer 12

ABCDE assesment

Question 13

What is the second step of managing a PE?

Answer 13

Give oxygen high flow 10-15L/min (probs use a non-re breathing mask)

Question 14

What would you do after giving oxygen if your patient is in pain?

Answer 14

Give morphine 10-15mg IV and metoclopramide

Question 15

If your patient is already critically ill at this point or a massive PE has been found, what should you consider doing?

Answer 15

Give thrombolysis now! (50mg bolus of alteplase)

Question 16

If not critically ill and patient has been given analgesia and oxygen, what is the next step?

Answer 16

Give IV LMWH or unfractionated heparin

Question 17

Your patient is oxygenated, received analgesia and heparin what measurement should you take to guide your treatment from this point?

Answer 17

Blood pressure

Question 18

The patient has a systolic above 90 what is the next treatment step?

Answer 18

Start loading dose of warfarin (5-10mg PO) and confirm diagnosis

Question 19

Your patient has a systolic below 90 what is the next step?

Answer 19

Start rapid colloid infusion and send to ICU

Question 20

If systolic remains below 90?

Answer 20

give doubutamine and more colloid

Question 21

If BP is still below 90 then what should you do?

Answer 21

IV adrenaline

Question 22

Your patient still has a systolic below 90 after 30-60 minutes of standard treatment, it is clinically definite PE what should you do?

Answer 22

Give thrombolysis (if no CIs to thrombolytics)

Question 23

After patient is stable, what long term management steps should be taken?

Answer 23

Compression socks, LMWH while warfarin takes affect to bring INR above 2, treat any underlying cause

Question 24

Prevention strategies?

Answer 24

Early post-op mobilisation, TED stockings, avoid the contraceptive pill, good anti coag

Question 25

Where do pulmonary embolisms usually originate from where?

Answer 25

A DVT in the legs or pelvis

Question 26

What is the problem with CTPA?

Answer 26

Highly nephrotoxic