PE + Pulm HTN + Cor Pulmonale Flashcards
DVT most likely in
Femoral vein
Popliteal vein
Pulmonary infarct happens immediately?
NO, brochial arteries providing alternate source
Embolus
Abnormal particle (fat, air, clot) circulating in blood
Pulm embolism
Path
RESPIRATORY
- alveolar dead space
- hypoxemia
- hyperventilation
HEMODYNAMIC
- reduced total area - Pulmonary vascular bed
- Local release of chemical mediators –> diffuse vasoconstriction
- UP pulm resistance
DEPEND ON SIZE OF EMBOLUS
Pulm embolism
Gen causes
THROMBOTIC
*blood
NON-THROMBOTIC
- air
- fat/bone marrow
- amniotic fluid (during/after delivery)
- foreign body (talc, IV use)
Pulm Embolism
Etiology philosophy
Virchow’s triad
*venous stasis (immobile, surgery)
*Hypercoagulability
(Hereditary, Preg, contraception/ERT, malignancy)
*vessel wall injury
(Trauma)
Pulm Embolism
Who is high risk?
- *****Ortho surgery (hip)
- **Post-CABG
- bed rest x1 week
- Pulm dz w/ 3+ days bed rest
- ICU admit
- Post-MI CCU admit
*male, AA, old, young=female (post-partum/preg, OCT), smokers
- SOB
- Cough
- Abrupt onset chest pain
Also *hemoptysis, leg pain, angina, syncope, palpitations
*most asymptomatic
Pulm embolism
Pulm Embolism
PE
- tachypnea
- rales (fine crackles)
- Tachycardia
- Prominent S2 (loud P2)
- fever
Other:
*DVT, trauma, murmur
Pulm Embolus
Find cause
- calf tenderness, erythema, circumference discrepancy
- hypercoagulable state = CBC (cell proliferation) (deficiency = Protein S/C, Factor 5 Leiden)
- trauma? (Long bone fractures, surgery)
Well’s test
DVT
- Cancer
- immobilization
- bedridden
- tenderness on DV system
- swollen entire leg
- calf swelling 3cm larger than other side
- pitting edema in symptomatic leg
- Collateral superficial veins (non-varicose)
Wells test
Pulm embolism
- Previous PE/DVT
- Tachycardia
- Recent surgery/immobilization
- DVT clinical signs
- Hemoptysis
- Cancer
Wells criteria
- low
- intermediate
- high
Pulm Embolism
- low = 0-1
- Intermediate = 2-6
- High = >/=7
DVT
- low = <0
- intermediate = <1-2
- High = >/=3
PERC Rule - out criteria (no other testing needed)
- Age <50 y/o
- HR <100bpm
- O2sat >/= 95%
- No hemoptysis
- No estrogen use
- No prior DVT/PE
- No unilateral leg swelling
- No surgery/trauma requiring hospitalization w/in past month
Pulm embolism ECG
S1 Q3 T3
possible RBBB????
Pulmonary Embolism
D-dimer
RULE OUT DVT/PE
- fibrin degradation
- up in thrombosis
- POSITIVE = clot somewhere (maybe not PE)
- NEGATIVE = definitely no clot anywhere
Pulm Embolism
CXR
MAKE SURE THERE IS NO COMORBID PROCESS
- Westmarks sign = pulm artery bigger than normal then just stops
- Hampton’s hump = triangular white patch (infarcted tissue)
Pulm embolism
VQ scan
- low radiation compared to CT/ no contrast dye
- Grading = “high/medium/low”
- pregger
Pulm Embolism
*CT pulm angiography
*High-Likelihood = Go-to test
- IV contrast dye (kidneys)
- much radiation = careful female
Pulm Embolism
Pulm Angiography
- GOLD STANDARD
- invasive
- high specificity/sensitivity
- MUCH contrast/radiation
- can use to administer thrombolytic
Pulm Embolism
Lower Extr. Ultrasound
- DVT in patient with PE —> Tx for PE
* test patency/compressability of large veins
PE
Dx Algorhythm
Low risk
- Wells Score - “Low”
- PERC rule out? Yes = A-OK
- PERC ? No= D-dimer
- D-dimer <500ng/mL? A-OK
- D-dimer >500ng/mL? CT angiography
- can do CT angio? DX
- Can’t CT or inconclusive? VQ scan = either yes OR further testing needed
PE
Dx Algorhythm
Intermediate Risk
- Intermediate Wells (2-6)
- D-dimer <500ng/mL? A-OK
- D-dimer >500ng/mL? CT angiography
- can do CT angio? DX
- Can’t CT or inconclusive? VQ scan = either yes OR further testing needed
PE
Dx Algorhythm
High Risk
- High probability PE >6
- CT angiography
- can do CT angio? DX
- Can’t CT or inconclusive? VQ scan = either yes OR further testing needed
Pulm Embolism
Tx
ANTI-COAG ****Antithrombin block (Heparin) *Vit K block (warfarin) *Factor 10a block *Thrombin block (dabigatran = surgery, very reversible) 3 MONTHS + body breaking down
Hemodynamically unstable? THROMBOLYTIC = Alteplase (rT-PA)
*High risk + bedridden + needing surgeries? IVC filter
Pulm Embolism
Prevention
Hospitalized? = Ambulation, compression stocking, pneumatic compression, Rx
At risk?
Smoking cessation, OBC cessation, ambulation, anticoag b/f travel
Pulm HTN
Pressure
Mean arterial (25mmHg rest)
PCWP/LVEDP <15mmHg (approximate L atrial pressure = RULE OUT LEFT SIDE HF AS CAUSE
Pulm HTN
Etiology
- 1ary
- 2ndary
1ary
- idiopathic pulm artery HTN
- familial
2ndary
- Infxn
- Collagen vascular dz
- Iatrogenic
- Respiratory (COPD, interstitial)
- DOE
- Fatigue
- Syncope
- Loud P2
- Early systolic ejection click +/- midsystolic ejection murmur
- JV distention
Pulm HTN
Pulm HTN
ECG
CXR
Catheter
ECG = “p pulmonale” = tall peaked P in Lead 2 (~1)
CXR= normal, maybe enlarged heart
Right heart catheter = artery pressure, PCWP
Pulm HTN
Tx
1ARY
- CCB
- endothelin receptor block, Phosphodiesterase inhibit, Prostanoid
2NDARY
Underlying condition
- fatigue/dyspnea
- tachypnea
- DOE
- peripheral edema/pitting
- angina
- split S2 (loud P2)
- early ejection click/systolic ejection murmur
- diastolic regurgitant murmur
- left parasternal heave
- hepatojugular reflex
Cor Pulmonale
Cor Pulmonale
ECG
High P, peaked, 1+2
R axis shift
Twave invert v1234
Cor Pulmonale
DX
Echocardiogram
NEEDED
- RV size
- regurgitant flow
- estimation of PA pressure w/ doppler
Cor Pulmonale
Dx
Right Heart Cath
- Swan Ganz Catheter
* Direct PA pressure measurment
Cor Pulmonale
Tx
Acute = fluids, correct cause
Chronic = Underlying dz, O2, Diuretics, vasodilators (nifedipine, diltiazem, nitrates), Digoxin
