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pHTN and pulmonary lung disease Flashcards

1
Q

Where do most emboli that cause PEs originate from? Where else?

A

Deep veins in the leg

Less commonly in the pelvic, renal, or UE veins

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2
Q

What percent of patients with a PE will be symptomatic?

A

less than 50%

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3
Q

What percent of isolated calf vein thrombi will propagate above the popliteal fossa?

A

25%

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4
Q

What percent of LE venous emboli being in the proximal veins without prior calf involvement?

A

20%

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5
Q

When emboli originate from the upper extremities, what is this usually due to?

A

PICC or other lines in place

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6
Q

What percent of calf DVTs will resolve spontaneously? What happens if they do not?

A

75%

Other 25% will develop into a proximal DVT

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7
Q

What is the risk of developing a PE with a clot that does not grow proximally from the popliteal vein?

A

Rare

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8
Q

What is a chronic PE?

A

Embolus that lodges in the pulmonary vasculature, and causes occlusion of a vessel

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9
Q

What happens to the BP with a massive PE?

A

SBP less than 90 or drop of greater than 40 mmHg in less than 15 minutes

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10
Q

Where do PEs lodge, generally?

A

Bifurcation of the main pulmonary artery (saddle)

lobar and peripheral arteries

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11
Q

What type of PEs are most likely to cause hemodynamic compromise?

A

large ones that occlude the main Pulmonary artery

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12
Q

What are the ssx of smaller PEs?

A

Usually affect the distal arteries and cause pleuritic chest pain.

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13
Q

What percent of emboli are associated with a document pulmonary infection

A

10%

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14
Q

When does RV failure occur with a PE?

A

If the embolus causes a 75% compromise in pulmonary blood flow

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15
Q

What is the most common presentation of a PE?

A

Dyspnea at rest or DOE
Pleuritic chest pain
Calf/thigh pain

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16
Q

Pleuritic chest pain from a PE indicates what about it?

A

That it has been there long enough (a day) to cause local inflammation/irritation

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17
Q

What causes hemoptysis with a PE?

A

Death of lung tissue

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18
Q

What causes wheezing with a PE?

A

Showering of clots throughout the pulmonary vasculature

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19
Q

What causes the crackles with a PE?

A

Atelectasis

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20
Q

What are the two most common exam findings with a PE?

A

Tachypnea

Tachycardia

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21
Q

What causes an accentuated P2?

A

pHTN

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22
Q

What are the components of the Well’s criteria?

A
  • CA
  • Immobilization/hypercoagubility
  • Local TTP
  • Leg swelling
  • Calf greater than 3 cm
  • Pitting edema
  • Collateral superficial veins
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23
Q

What is the value of Well’s criteria that warrants further workup? What is an alternative diagnosis is more likely?

A

Greater than 2

If alternative more likely, than subtract 2

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24
Q

What is the pattern of ABG findings with a PE?

A

Respiratory alkalosis and hypoxemia

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25
Will the BNP be elevated with a PE?
can be
26
What percent of patients with a PE will have an elevated troponin?
30-50%
27
What is a D-dimer?
FIbrin degradation product
28
What is the EKG pattern that can be seen with a PE?
S1 Q3 T3
29
What, besides the SQT133 pattern can be found on an EKG with a PE?
RV strain | Incomplete RBBB
30
What is the most common EKG finding with a PE?
Sinus tach
31
What are the "classic" CXR findings with a PE?
Hampton's hump and Westermark's sign
32
What is Hampton's hump?
very insensitive but specific wedge shaped opacity on CXR that indicates a PE causing a wedged area of infarction
33
What is the Westermark's sign?
Very insensitive but specific sign for a PE that consists of a loss of the vascular markings in a lung d/t clot showering
34
What is the gold standard for PE detection? What is usually used?
Gold = pulmonary angiography CT pulmonary angio
35
Who gets a VQ scan for a PE?
Pts who cannot tolerate contrast (CKD)
36
What is the treatment for a PE?
Anticoagulation ASAP: - Unfractionated heparin - LMWH
37
When are thrombolytics indicated for a PE?
For massive PE with hemodynamic compromise (less than 90 mmHg DBP)
38
What, besides thrombolytics, can be used to treat a large PE? (2)
Surgical thrombectomy | Catheter based therapies
39
When is a surgical thrombectomy appropriate?
For patients that cannot tolerate thrombolytics or who have recently undergone surgery
40
What are the two main sequelae of massive PEs?
Hypotension/shock | RV failure
41
What are the treatments for cardiogenic shock or RV failure, secondary to a PE?
Inotropes (NE, dobutamine) NO RVAD ECMO
42
What is the use of an IVC filter?
Filter that will break down clots and prevent them from passing as a whole to the heart
43
What are the indications for an IVC filter?
failure of anticoagulants | Acute PE when additional thrombi could be lethal
44
What are the outpatient meds to give to pts post PE? How long should these be used for?
Anticoagulants likes warfarin 3 months if reversible cause Extended if there are recurrent events
45
When should f/u be done with a massive PE, and what should be done? Why?
3-6 month echo to look for pHTN
46
What is the normal pulmonary artery pressure? What is the definition of pHTN?
8-20 pHTN = greater than 25 mmHg at rest
47
What is group 1 of the WHO classification for pHTN?
pHTN (precapillary PAH)--pHTN from the right side of the heart
48
What is group 2 of the WHO classification for pHTN?
Pulmonary venous HTN from left sided heart disease
49
What is group 3 of the WHO classification for pHTN?
PH from lung disease and/or hypoxia
50
What is group 4 of the WHO classification for pHTN?
Chronic thromboembolic PH
51
What is group 5 of the WHO classification for pHTN?
PH with unclear, multifactorial mechanisms
52
What is the most common cause of pHTN worldwide?
Schistosomiasis
53
What are the usual ssx of pHTN (early and late)? How do these progress?
Slow onset of DOE Late ssx: - chest pain - syncope - right heart failure
54
How long is the delay between onset of pHTN and diagnosis?
2 years
55
What is the best methodology of diagnosing pHTN? What is the definitive way to diagnose pHTN?
echo IV cath of the right heart is definitive
56
If pHTN is suspected on echo, what should you do for the workup?
Look for secondary causes Determine need for right heart cath
57
What are the two tests that are beneficial to r/o other causes of pHTN or RV failure?
V/Q scan (PE) | PFTs (pulmonary causes)
58
What is the test of choice for a chronic pulmonary embolism?
VQ scan
59
What is the difference between group 1 and 2 pHTN according to the WHO classification?
PAWP is greater than 15 in group 2
60
What is a vasodilator challenge and what is it used for?
Give 100% O2 and see if sat improves Positive indicates Left heart failure
61
What are the criteria for a good response to the vasodilator challenge?
Mean PAP less than 40 mmHg Mean PAP decreases by 10 mmHg CO increases or stays constant
62
What is the incidence (relatively) of isolated pHTN? Which gender is more often affected?
Rare | Women
63
What is known about the etiology of isolated pHTN?
Genetic and environmental factors cause proliferation, thrombosis, and vasoconstriction of the pulmonary vasculature
64
What is the treatment for group I pHTN pts?
DHP CCBs if responsive
65
What is the treatment for group I pHTN pts that do not respond to CCBs? What is the role of each?
PDE-5 inhibitors (increases NO) Prostacyclins (increases PGI2) ERAs (Binds to ET-1 to prevent remodeling)
66
What are the components of the adjunctive therapy for pHTN?
Diuretics for overload | Na restriction
67
What is the treatment for Groups II pHTN pts?
Treat the right heart failure
68
What is the treatment for Group III pHTN pts?
Treat underlying lung disease
69
What is the treatment for Group IV pHTN pts?
Pulmonary thromboendarterectomy
70
What is the treatment for Group V pHTN pts?
No specific therapy
71
What is the goal of therapy with treatment for PAH?
Get them to functional class I or II NOT treat the numbers, since RV failure can also show decreased numbers
72
What are the high risk groups for group I PAD?
Scleroderma | Family h/o it

Respiratory (34 decks)

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