PE, clinical features, investigations and treatment

Question 1

What are the clinical features of DVT

Answer 1

1. Small - progressive SOB, pulmonary hypertension and RHF
2. Medium - Haemoptysis, chest pain and breathlessness
3. Large - CVS shock , low BP and central cyanosis and death

Question 2

What are the risk factors for PE

Answer 2

• FH of thrombophilia
• Obesity
• Pregnancy
• Pelvic obstruction
• Contraceptive pill
• Surgery
• immobility
• pulmonary hypertension

Question 3

Prevention of PE

Answer 3

• Early post-op mobilisation
• TED compression stockings
• Subcutanous low dose of LMW heparin - Daltaperin
• Calf muscle excersies

1. Oral anticoagulants

• ​Dabigatran
• Rivaroxiban or apaxiban

Question 4

what will the presenting complaints be

Answer 4

• Sudden onset of SOB
• Pleuritic chest pain
• Haemoptysis
• Leg pian/swelling
• collapse and death

Question 5

What are the signs of PE

Answer 5

• Tachycardiac, tachypnea, cyanosis, fever, low BP
• Crackles, pleural rub and pleural effusions, raiased JVP decreased breath dounds an dullness
• ABGs - Low PaO2, SaO2 and normal or low PaCo2 - type 1

1. ​CRX

• ​Basal collapse
• Consolidation
• Pleural effusion

Question 6

What are the investigations of PE

Answer 6

• 1^st line = CT pulmonary angiogram CTPA
• PESI - pulmonary embolism severity index
• FBC, ABG
• CXR - dilater pulmonary arteires small effusion and decreased lung markings
• ECG - Right heart strain - T inversion - V1-V3
• Echocardiogram - Right heart dilation
• V/Q scanning rarely performed
• d-dimer high sensitivity but low specificity

Question 7

What are the investigations for the underlying cause

Answer 7

1. Consider cancer, surgery, pregnanct etc
2. Autoantibodies - SLE
3. Thrommbophillia screen

• ​Anti thrombin III deficiency
• Protein S or C deficiency

Question 8

What is the managment for PE

Answer 8

1. Start of LMWH once daily injection

• At same time start on Warfarin (monitoring)
• When the INR > 2 stop heparin
• Continue warfarin for 3-6 months
• Treat underlying causes

​ 2. Alternative - Oral anticogaulants

• Dabigatran- Anti-thrombin
• APaxiban or revaroxiband - Xa inhbit

Question 9

How do we Monitor warfarin

Answer 9

INR - pro-thrombin time

1. ​Target

• ​2-3 - first event
• 3.0 - more or recurrent
• 3.5 - If recurrent whilst on warfarin

Question 10

How and when do we carry out thrombolysis

Answer 10

If life thretening PE only

• with Tissue plasminogen activator - TPa
  
  • ​BP <90 for 15 mins
  • Severe hypoxia or cardiac arrest
  • Contraintriductions - haemorrhag, stroke TIA,pregnancy, GI bleeding

Question 11

Other treatments

Answer 11

• IVC filter
• Intra-catheter directed thrombolysis
• EKOS - ultrasound enhanced catheter thrombolysis

Question 12

Antidot for warfarin or heparin

Answer 12

• Warfarin = Vit K
• Heparin = Protamine