PE -Goya Flashcards
Where do most PEs originate?
DVT in the lower extremities
preventing DVT can prevent PE
What are some risk factors for PE?
- immobilization–> dec venous blood flow
- 50-60 yo
- women on birth control
- estrogen therapy
- pregnancy
- a fib and CHF
- trauma / burns
- cancer
- genetic/acquired thrombophilia
What is the only consistent finding with a PE?
tachypnea
can also get dyspnea and chest pain –> acute SOB and CP
What chest x-ray findings suggest PE?
Hampton’s Hump (infarcted lung) & Westermark sign (abrupt cut off of the pulm. A)
Normal CXR with severe dyspnea & hypoxemia suggest PE
What are some common tests used to help diagnose a PE?
- ABG: hypoxemia or a widened A-a gradient, hypocarbia in acute PEs
- D-dimer=highly sensitive but not specific –> used to r/o PE
- CT angiogram-95% sensitive in dx PE. also can detect pulmonary abnormalities ***what we normally use
- VP scan –> when pts cannot take IV contrast**
- pulmonary angiogram
What is the gold standard for diagnosing PE?
pulmonary angiogram
much more invasive than CTA because go in to the pulmonary A
What is often used for diagnosing PEs before invasive tests?
Doppler Ultrasound ==> if detect a DVT, can assume that the pt has a PE
caution in previous DVTs–> pt may not return to normal with recurrent DVT
A 50-year-old man is evaluated in the emergency department for 4-day history of pain, swelling and erythema of left leg. There is not history of recent surgery, trauma, recent travel or infection. On physical exam , temp is 100.0o F, blood pressure is 135/62 mmHg, Pulse rate 68/min, resp rate is 16/min. Examination of left lower leg shows tenderness on posterior portion of leg and 1 cm increase in circumference compared to right leg at 10 cm below tibial tuberosity. Ther is no evidence of varicose vein.
Which of the following is most appropriate next step in diagnosis?
A. Ventilation perfusion scan
B. Venography of left leg
C. Assay for plasma d-dimer
D. Measurement of antithrombin III.
C. Assay for plasma d-dimer
if D-dimer is -, it is NOT a PE
What are the absolute contraindications to anticoagulation?
Active Bleeding
Platelet count < 20,000
Neurosurgery, ocular surgery or intracranial bleeding with the past 10 days
What are the initial and long term therapies for thromboembolic disease?
Initial Therapy:
- Unfractionated Heparin (continuous IV infusion)
- Low Molecular Weight Heparin (LMWH) (*tx of choice in out pt DVT) (do not need to monitor PTT levels)
Long Term Therapy:
- Coumadin
- New oral anticoagulants
*normally give LMWH and coumadin together
What are the contraindications for giving LMWH?
Renal Failure
Obesity
Allergy to Heparin
Contraindications to the use of anticoagulation
What determines how long a pt with a PE should remain on oral anticoagulation?
Total duration is dependent on predisposing risk factors for DVT:
Treat for 3 months and reassess
if low risk of bleeding, continue to treat for 6 months.
if high risk for bleeding, treat for 3 months only
if coagulation problems (deficiency of antithrombin, protein C or S, factor V leiden cancer), treat indefinitely
When should thrombolytic treatments be given?
for PE with hypotension or high risk hypotension
activates plasminogen to lyse clot
What are the 2 surgical options for PE treatment and when should they be used?
embolectomy should only be used with documented massive PE who are in refractory shock
inferior vena cava interruptions are used in prophylaxis against recurrent PEs despite adequate anticoagulation or if there is contraindication to anticoagulation
-IVC filters did not improve mortality and has a lot of complications
