PE Management Flashcards
What percentage of patients with a PE present with sudden unexpected death?
25%
This statistic highlights the severity of pulmonary embolism.
List common symptoms of a pulmonary embolism (PE).
- Dyspnoea
- Pleuritic chest pain
- Cough
- Hemoptysis
- Dizziness or syncope
Hemoptysis is secondary to infarcted lung tissue.
What are some risk factors for pulmonary embolism?
- Recent surgery
- Recent fractures
- Recent immobility
- Family history
- Obesity
- Malignancy
- Infection
- Pregnancy
- Medications (COCP, HRT)
COCP refers to combined oral contraceptive pills, and HRT refers to hormone replacement therapy.
What is a common finding during a cardiorespiratory exam for a PE?
- Pleural rub
Signs of hemodynamic compromise: - Tachypnoea
- Tachycardia
- HoTN
- Cyanosis
- Signs of DVT on lower limb
Clinical exam is often unremarkable despite these signs being present.
PE Investigations
● ECG
- Outrule MI or AF
- Sinus tachycardia most often seen
- Classic S1Q3T3 change seen in <20% of patients:
● Bloods:
- FBC
- U&E
- CRP
- Crossmatch
- D-dimer (will be raised post-op)
- Troponin (outrule MI)
- B-HCG (consider pregnancy)
● CXR (outrule other lung pathology)
- Possible findings include a wedge-shaped opacification (Hampton’s hump)
What does the PERC score help with in relation to pulmonary embolism?
Rules out PE if all criteria are absent
If all PERC criteria are absent, the chance of PE is <2%.
What is the classic ECG finding associated with pulmonary embolism?
S1Q3T3 change
This change is seen in <20% of patients and includes S-wave in lead I and Q-wave with inverted T wave in lead III.
What blood tests are typically performed when investigating a suspected PE?
- FBC
- U&E
- CRP
- Crossmatch
- D-dimer
- Troponin
- B-HCG
D-dimer will be raised post-op, and B-HCG is considered in cases of pregnancy.
PE Wells score greater than 4, next step?
Immediate CTPA (CT pulmonary angiogram)
give interem DOAC until scan performed
■ Positive: Dx of PE
■ Negative: consider proximal leg vein US
PE Wells score less than 4, next step?
Perform D-dimer
- Positive: perform CTPA (DOAC anticoagulation until scan performed)
- Negative: outrule Dx of PE
PE investigation of choice in renal impairment (e.g. GFR < 15) or pregnancy?
V/Q scan:
○ Ventilation: krypton 81m inhaled (pure gamma emitter)
○ Perfusion: technetium 99m injected
○ PE will appear as an area of ventilation but no perfusion
What is the treatment of choice for anticoagulation in PE?
How long continued for?
DOAC (e.g. apixaban 10 mg BD)
Continued for >3 months (provoked), 3-6 months (active cancer), or 6 months (unprovoked)
What is the management for haemodynamic compromise in a PE?
- Flowtriever (catheter pulmonary thrombectomy)
- Thrombolysis with alteplase (10 mg IV bolus over 1 minutes followed by 90 mg over 2 hours)
Thrombolysis involves administering 10 mg IV bolus over 1 minute followed by 90 mg over 2 hours.
What imaging is the investigation of choice in renal impairment or pregnancy for PE?
V/Q scan
PE will appear as an area of ventilation but no persusion
This scan uses krypton 81m inhaled for ventilation and technetium 99m injected for perfusion.
What is the follow-up treatment for recurrent PEs?
IVC filters
IVC filters are used to prevent further embolic events.
