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Clin Med II > PE and lung nodules > Flashcards

PE and lung nodules Flashcards

1
Q

PE definition

A
  • obstruction of pulmonary arteries or one of its branches

- usually thrombus travels from elsewhere in body

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2
Q

causes of PE

A
  • thrombus (VTE)- most common
  • tumor
  • fat
  • air
  • other substances
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3
Q

classification of PE

A
  • acute- si/sx immediately
  • subacute- presents over days or weeks
  • chronic
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4
Q

possible locations for PE

A
  • saddle
  • segmental
  • subsegmental- difficult to pick up on CTA
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5
Q

saddle PE

A
  • massive PE in main pulmonary arteries

- very likely to cause hemodynamic instability

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6
Q

risk factors for PE

A
  • post op- especially ortho surgery
  • sedentary state
  • malignancy
  • hx of VTE
  • pregnancy
  • OCP
  • obesity
  • heavy cigarette smoking
  • inherited hypercoag disorders
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7
Q

ortho surgeries that are highest risk of PE

A
  • THR
  • TKR
  • hip fx surgery
  • pelvic fx
  • multiple fx from severe trauma
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8
Q

when can an embolism cause a stroke rather than PE

A
  • if pt has PFO or ASD

- allows the embolus to skip the lungs

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9
Q

symptoms of PE

A
  • sudden onset SOB
  • pleuritic chest pain
  • heart palpitations/ tachycardia
  • DVT
  • hypoxia
  • tachypnea
  • consider risk factors
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10
Q

hemodynamically unstable pts from PE

A
  • most likely to die from PE
  • most likely to get fibrinolytic therapy
  • hypotension < 90 for > 15 min
  • severe RB failure -> death from shock
  • elevated troponin from right heart strain
  • death occurs within first 2 hours
  • risk of death stays elevated for 72 hours
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11
Q

diagnosis of PE

A
  • use wells criteria
  • D dimer for low probability pts
  • CXR- usually negative
  • chest CTA with contrast- gold standard
  • V/Q scan when pt cannot get CTA
  • venous US- look for loss of vein compressability
  • EKG
  • echo- right heart strain
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12
Q

PERC- pt does NOT need D dimer if all of the following are negative:

A
  • age < 50
  • HR < 100
  • oxygen > 95
  • no hemoptysis
  • no estrogen use
  • no prior DVT or PE
  • unilateral leg swelling
  • no sx or trauma requiring hospitalization in last 4 weeks
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13
Q

EKG features of PE

A
  • sinus tachycardia
  • S1 Q3 T3
  • RV strain- T wave inversion in R and anterior precordial leads
  • complete or incomplete RBBB
  • nonspecific St or T wave changes
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14
Q

treatment options for PE

A
  • risk stratify to determine if primary or secondary tx
  • primary- thrombolysis, reserved for high risk pts
  • secondary- anticoag or IVC filter
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15
Q

anticoag tx for PE

A
  • stabilizes clot but doesnt dissolve clot
  • started immediately
  • LMWH injection -> warfarin bridge
  • fondaparinux injection -> warfarin bridge
  • unfractionated heparin as continuous infusion -> warfarin bridge
  • Xa inhibitors
  • dabigatran
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16
Q

considerations for anticoag tx

A
  • pt compliance
  • cost
  • most C/I if CrCl < 30
  • if reversal agent needed
  • malignancy- use LMWH
  • pregnancy- use LMWH
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17
Q

provoked clots

A
  • post op
  • trauma
  • estrogen exposure
  • usually low rate of recurrence
  • anticoag tx for 3-6 mo
18
Q

unprovoked clots

A
  • idiopathic
  • long haul air travel
  • some hypercoag conditions- anticardiolipid ab
  • indefinite anticoag tx
19
Q

IVC filters

A
  • active bleeding precludes anticoagulation
  • recurrent VTE despite anticoag tx
  • high risk pts that are not candidates for fibrinolysis
20
Q

complications of IVC filters

A
  • caval thrombosis
  • bilateral leg swelling
  • doubled DVT rate
21
Q

VTE prophylaxis

A
  • heparin or LMWH at lower doses in hospitalized pts
  • used in high risk ortho pts- usually LMWH or Xa inhibitors
  • ASA not recommended as sole agent
22
Q

PE prognosis

A
  • recurrence rate depends on adequate anticoag tx
  • depends on if its provoked or unprovoked
  • PH is long term sequelae
  • death- untreated mortality rate is 30%
  • most deaths occur in first week following dx
23
Q

pulmonary nodule

A
  • lesion that is within and surrounded by pulmonary parenchyma
  • aka coin lesion
  • < 3 cm in size
  • not assoc with atelectasis or LAD
24
Q

pulmonary mass

A
  • > 3 cm in size
25
Q

dx of pulmonary nodules

A
  • CXR- can miss small nodules
  • CT
  • PET
  • MRI
26
Q

chest CT for pulmonary nodules

A
  • more sensitive than CXR for small nodules
  • usually get CT if there is abnormal CXR finding
  • higher radiation and more expensive
  • standard slices- 3.5-5 mm
  • high res slices- 1 mm
27
Q

soft tissue windows in CT

A
  • look for LAD, vessels, and soft tissue

- usually done with contrast

28
Q

lung tissue windows

A
  • used to det what is embedded within lung tissue i.e. nodules
  • usually no contrast
29
Q

when is CT C/I

A
  • IV contrast allergies
  • renal insufficiency
  • pregnancy
  • cant accommodate pts > 400 lbs
30
Q

PET

A
  • uses FDG contrast
  • very sensitive, less specific
  • can be used for staging and monitoring tx of cancer
  • very expensive, not always covered by insurance
  • cant differentiate between inflammation and malignancy
31
Q

what is SUV

A
  • standardized uptake value in PET scan
  • tells you how “hot” a lesion is
  • SUV > 3 is beyond physiologic uptake
32
Q

what malignancies tend to have false negative PET scans

A
  • adenocarcinomas in situ

- carcinoid tumors

33
Q

chest MRI

A
  • used to assess tumor size, extent, and invasion into adjacent structures
  • good to determine tissue plants- fat, muscle, bone, vessel
  • no radiation
  • limited use for solitary pulm nodules no adjacent to other structures
34
Q

when are chest MRI C/I

A
  • metal implants or pacemakers
35
Q

when is PET not useful

A
  • if nodule is < 8-10 mm

- too small to be detected on PET

36
Q

size of nodules

A
  • usually the larger the size the more likely to be malignant
  • > 20 mm has 75% chance of malignancy
  • 8-20 mm has 15% chance of malignancy
37
Q

nodule borders

A
  • malignant lesions have irregular or spiculated* borders
  • benign usually smooth and discrete
  • metastatic lesions can have smooth and discrete borders but tend to be diffuse
38
Q

nodule calcification

A
  • usu seen in granulomatous disease and hamartomas (both benign)
  • osteosarcomas and chrondrosarcomas tend to have pulmonary calcifications
39
Q

nodule growth

A
  • malignant lesions are slow growing, increase in size over 4-6 mo
  • benign lesions grow rapidly- usually infectious or inflammatory
40
Q

air bronchogram

A
  • collapsed lung around an airway
41
Q

benign causes of nodules

A
  • infections- 80%
  • inflammatory- 10%
  • hemartmoas- 10%
42
Q

hemartoma

A
  • bengin nodule
  • comprised of cartilage, fat and muscle
  • “popcorn” calcifications

Clin Med II (16 decks)

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