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Pulmonology > PE + Pulm HTN + Cor Pulmonale > Flashcards

PE + Pulm HTN + Cor Pulmonale Flashcards

1
Q

DVT most likely in

A

Femoral vein

Popliteal vein

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2
Q

Pulmonary infarct happens immediately?

A

NO, brochial arteries providing alternate source

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3
Q

Embolus

A

Abnormal particle (fat, air, clot) circulating in blood

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4
Q

Pulm embolism

Path

A

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

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5
Q

Pulm embolism

Gen causes

A

THROMBOTIC
*blood

NON-THROMBOTIC

  • air
  • fat/bone marrow
  • amniotic fluid (during/after delivery)
  • foreign body (talc, IV use)
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6
Q

Pulm Embolism

Etiology philosophy

A

Virchow’s triad
*venous stasis (immobile, surgery)

*Hypercoagulability
(Hereditary, Preg, contraception/ERT, malignancy)

*vessel wall injury
(Trauma)

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7
Q

Pulm Embolism

Who is high risk?

A
  • *****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

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8
Q
  • SOB
  • Cough
  • Abrupt onset chest pain

Also *hemoptysis, leg pain, angina, syncope, palpitations

*most asymptomatic

A

Pulm embolism

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9
Q

Pulm Embolism

PE

A
  • tachypnea
  • rales (fine crackles)
  • Tachycardia
  • Prominent S2 (loud P2)
  • fever

Other:
*DVT, trauma, murmur

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10
Q

Pulm Embolus

Find cause

A
  • calf tenderness, erythema, circumference discrepancy
  • hypercoagulable state = CBC (cell proliferation) (deficiency = Protein S/C, Factor 5 Leiden)
  • trauma? (Long bone fractures, surgery)
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11
Q

Well’s test

DVT

A
  • 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)
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12
Q

Wells test

Pulm embolism

A
  • Previous PE/DVT
  • Tachycardia
  • Recent surgery/immobilization
  • DVT clinical signs
  • Hemoptysis
  • Cancer
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13
Q

Wells criteria

  • low
  • intermediate
  • high
A

Pulm Embolism

  • low = 0-1
  • Intermediate = 2-6
  • High = >/=7

DVT

  • low = <0
  • intermediate = <1-2
  • High = >/=3
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14
Q

PERC Rule - out criteria (no other testing needed)

A
  • 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
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15
Q

Pulm embolism ECG

A

S1 Q3 T3

possible RBBB????

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16
Q

Pulmonary Embolism

D-dimer

A

RULE OUT DVT/PE

  • fibrin degradation
  • up in thrombosis
  • POSITIVE = clot somewhere (maybe not PE)
  • NEGATIVE = definitely no clot anywhere
17
Q

Pulm Embolism

CXR

A

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)
18
Q

Pulm embolism

VQ scan

A
  • low radiation compared to CT/ no contrast dye
  • Grading = “high/medium/low”
  • pregger
19
Q

Pulm Embolism

*CT pulm angiography

A

*High-Likelihood = Go-to test

  • IV contrast dye (kidneys)
  • much radiation = careful female
20
Q

Pulm Embolism

Pulm Angiography

A
  • GOLD STANDARD
  • invasive
  • high specificity/sensitivity
  • MUCH contrast/radiation
  • can use to administer thrombolytic
21
Q

Pulm Embolism

Lower Extr. Ultrasound

A
  • DVT in patient with PE —> Tx for PE

* test patency/compressability of large veins

22
Q

PE

Dx Algorhythm

Low risk

A
  • 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
23
Q

PE

Dx Algorhythm

Intermediate Risk

A
  • 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
24
Q

PE

Dx Algorhythm

High Risk

A
  • High probability PE >6
  • CT angiography
  • can do CT angio? DX
  • Can’t CT or inconclusive? VQ scan = either yes OR further testing needed
25
Q

Pulm Embolism

Tx

A 
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

26
Q

Pulm Embolism

Prevention

A

Hospitalized? = Ambulation, compression stocking, pneumatic compression, Rx

At risk?
Smoking cessation, OBC cessation, ambulation, anticoag b/f travel

27
Q

Pulm HTN

Pressure

A

Mean arterial (25mmHg rest)

PCWP/LVEDP <15mmHg (approximate L atrial pressure = RULE OUT LEFT SIDE HF AS CAUSE

28
Q

Pulm HTN

Etiology

  • 1ary
  • 2ndary
A

1ary

  • idiopathic pulm artery HTN
  • familial

2ndary

  • Infxn
  • Collagen vascular dz
  • Iatrogenic
  • Respiratory (COPD, interstitial)
29
Q
  • DOE
  • Fatigue
  • Syncope
  • Loud P2
  • Early systolic ejection click +/- midsystolic ejection murmur
  • JV distention
A

Pulm HTN

30
Q

Pulm HTN

ECG
CXR
Catheter

A

ECG = “p pulmonale” = tall peaked P in Lead 2 (~1)

CXR= normal, maybe enlarged heart

Right heart catheter = artery pressure, PCWP

31
Q

Pulm HTN

Tx

A

1ARY

  • CCB
  • endothelin receptor block, Phosphodiesterase inhibit, Prostanoid

2NDARY
Underlying condition

32
Q
  • 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
A

Cor Pulmonale

33
Q

Cor Pulmonale

ECG

A

High P, peaked, 1+2

R axis shift

Twave invert v1234

34
Q

Cor Pulmonale

DX
Echocardiogram

A

NEEDED

  • RV size
  • regurgitant flow
  • estimation of PA pressure w/ doppler
35
Q

Cor Pulmonale

Dx
Right Heart Cath

A
  • Swan Ganz Catheter

* Direct PA pressure measurment

36
Q

Cor Pulmonale

Tx

A

Acute = fluids, correct cause

Chronic = Underlying dz, O2, Diuretics, vasodilators (nifedipine, diltiazem, nitrates), Digoxin

Pulmonology (12 decks)

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