PEs

Question 1

VTE –>

Answer 1

2/3 DVT

1/3 PE

Question 2

PE sources

Answer 2

DVT = 70%

or: R heart, UE, renal, iliac or hepatic veins

Question 3

factors in thrombosis

Answer 3

stasis
endothelial changes
hypercoagulable states

Question 4

PE risk factors

Answer 4

immobilization
stroke
cancer (+Tx)
CHF
obesity
age
preg
catheters
thrombotic disorders
thrombophilia

Question 5

PE progression (path)

Answer 5

emboli ups puml vascular resistance
RV cant match afterload
electro-mechanical dissociation –> death

Question 6

PE outcome progression

Answer 6

shock
cardiac arrest
sudden death

Question 7

definition of high risk (massive) PE

Answer 7

has RV failure
hypotension/syncope
high PAP

Question 8

what else can look like a PE?

Answer 8

MI
pneumonia
CHF
Asthma, COPD
cancer
cardiac tamponade 
pneumothorax
rib fracture
dissecting thoracic aneurysm
pulm HTN
panic attack

Question 9

PE signs on ECG

Answer 9

P pulmonale

R axis deviation

Question 10

PE on CXR

Answer 10

hampton’s hump
Westermark sign
Filling defect/cut off sign

Question 11

PE ABGs

Answer 11

low pCO2
low pO2
wide A-a gradient

Question 12

D-dimer value fro PE

Answer 12

high NPV

low PPV

Question 13

conditions with high D-dimer

Answer 13

malignancy
severe infection
aortic dissection
trauma
MI
stroke
liver or renal disease
DIC
preg/preeclampsia
CHF
surgery
sickle cell

Question 14

d-dimer

Answer 14

degradation product of crosslinked fibrin
useful to rule out a clot
ELISA assays best

Question 15

how to check for DVT

Answer 15

venous doppler ultrasonography

loss of compressibility

Question 16

V/Q scan

Answer 16

inhale tracers
look for hypoventilation (perfusion-vent mismatch)
prolonged washout shows air trapping

Question 17

perfusion scan

Answer 17

IV tracers

areas of occlusion aren’t radio labeled –> cold on imaging

Question 18

spiral CT angiography

Answer 18

method of choice
IV contrast given
see filling defect

Question 19

spiral CT angiography caution

Answer 19

renal insufficiency
IV contrast allergy
(no metformin for 48 hrs)

Question 20

gold standard for PE Dx

Answer 20

pulmonary angiography

Question 21

pulmonary angiography relative contraindications

Answer 21

pregnancy
renal insufficiency
R heart thrombus

Question 22

indicators of sub-massive PE on echo

Answer 22

RV dilation
McConnell sign
paradoxical septal wall motion
systolic pulm HTN
RV/LV ED diameter ratio

Question 23

McConnell sign

Answer 23

RV free wall hypokinesis w/ normal apical contraction

Question 24

when to do an echo

Answer 24

anyone with suspected massive or unstable PE

or pts for thrombolysis

Question 25

what to do if serious bleeding after thrombolytics

Answer 25

stop rt-PA give cryoprecipate, FFP and platelets consult neuro

Question 26

PE biomarkers

Answer 26

``` troponin I (high NPV) BNP (low PPV) ```

Question 27

when to do thromboletomy

Answer 27

massive PE where thrombolysis is contraindicated | pts w/ chronic thromboembolic pulm HTN

Question 28

IVC filter placement

Answer 28

for pts w/ recurrent PE despite anticoag therapy contraindication for anticoagulation (bleeding) use for hemodynamic or resp compromise for pts who had an embolectomy

Question 29

how long to treat post PE

Answer 29

``` 1st one w/ risk factors: 3-6 mo 1st idiopathic: 6 mo 2+ ones: indefinite 1 life threatening: indefinite hypercoagulable state: indef ```