PE Post THR

Question 1

Dad had a clot, non-compliant with medication, suffering from haemoptysis

Wells Score

Answer 1

https: //cks.nice.org.uk/topics/pulmonary-embolism/management/suspected-pulmonary-embolism/
https: //thorax.bmj.com/content/thoraxjnl/58/6/470.full.pdf

Clinical features of deep vein thrombosis (DVT; minimum of leg swelling and pain with palpation of the deep veins) — plus 3 points.

Heart rate greater than 100 beats per minute — plus 1.5 points.

Immobilization for more than 3 days or surgery in the previous 4 weeks — plus 1.5 points.

Previous DVT or PE — plus 1.5 points.

Haemoptysis — plus 1 point.

Cancer (receiving treatment, treated in the last 6 months, or palliative) — plus 1 point.

An alternative diagnosis is less likely than PE — plus 3 points. Alternative conditions to consider include:

Respiratory conditions, such as pneumothorax, pneumonia, and acute exacerbation of chronic lung disease.

Cardiac causes, such as acute coronary syndrome, acute congestive heart failure, dissecting or rupturing aortic aneurysm, and pericarditis.

Musculoskeletal chest pain. Note that chest pain with chest wall palpation occurs in up to 20% of people with confirmed PE.

Gastro-oesophageal reflux disease.

Question 2

Dad had a clot, non-compliant with medication, suffering from haemoptysis

Investigations

Answer 2

Wells score of more than 4 points (PE likely) - immediate CTPA

Wells score of 4 points or less (PE unlikely), offer a D-dimer test with the result available within 4 hours

Secondary care investigations

• ABG but PO2 can be normal in 20%
• CXR and ECG to exclude alternative diagnoses
• Lower limb compression venous US
• Ventilation-perfusion or perfusion scintigraphy (isotope lung scanning) — may be carried out in certain circumstances (for example, half-dose perfusion scintigraphy in pregnancy).
• Echocardiography — for people with hypotension (clinically ‘massive’ PE). The absence of right heart failure excludes PE.

Question 3

Treatment

Answer 3

If interim therapeutic anticoagulation is required:
Offer apixaban or rivaroxaban first line, and if these are not suitable, low molecular weight heparin (LMWH) for at least 5 days followed by dabigatran or edoxaban, or LMWH concurrently with a vitamin K antagonists for at least 5 days.

Take into account comorbidities, contraindications and the person’s preferences when choosing anticoagulation treatment.

Carry out baseline blood tests including full blood count, renal and hepatic function, prothrombin time (PT) and activated partial thromboplastin time (APTT).

Question 4

Indications for surgical embolectomy

Answer 4

1. Where there are absolute contraindications to thrombolysis
2. Where it has failed and the patient is
   critically ill

Pulmonary embolectomy is indicated for patients that develop massive or sub-massive PE:

• within 10 days of major surgery
• within 2 months after craniotomy or spinal surgery and patients with intracranial haemorrhage
• because thrombolysis is contraindicated in these patients, who have a high risk of re-bleeding

Question 5

Indications for thrombolysis

Answer 5

• Massive PE
• Circulatory collapse
• 50 mg alteplase iv