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(ZUZ) Respiratory MED > Pul embolism > Flashcards

Pul embolism Flashcards

1
Q

What is PE?

A

Pulmonary infarction due to embolism and occlusion, or obstruction, of the pulmonary artery and/or one of its branches. from the right side of the heart

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2
Q

Type of emboli

A
  • Thrombus
  • tumour
  • air
  • amniotic fluid
  • fat (fracture)
  • bullet
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3
Q

Clinical severity: Non-massive, Sub-massive, Massive

A
  • Non-massive: haemodynamically stable and no evidence of right heart strain
  • Sub-massive: haemodynamically stable, but evidence of right heart strain on imaging (e.g. CT, ECHO) or (and/or evidence of myocadial necrosis) biochemistry (e.g. elevated troponin)
  • Massive: haemodynamic instability.
    hypotension/ imminent cardiac arrest
    signs of right heart strain on CT / Echo
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4
Q

Location: where can they be found and what are they called?

A
  • Segmental and subsegmental: lower order pulmonary vessels. Unilateral or bilateral occlusion
  • Lobar: right or left main pulmonary arteries. Unilateral or bilateral occlusion
  • Saddle: embolus lodged at the bifurcation of the pulmonary arteries (3-6% of cases)
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5
Q

Risk factors:

A
  • Pregnancy/post-partum
  • prolonged immobilisation - long haul flight/bed rest
  • COCP or HRT
  • Malignancy (Abdominal/ Pelvic/ Advanced/ Metastatic)
  • Recent surgery >30 mins
  • Medications
  • Fracture
  • Varicose veins
  • Obesity
  • Recent previous VTE - DVT/PE
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6
Q

Hypercoagulable diseases that can PE?

A
  • Antithrombin 2 deficiency
  • Protein C or S deficiency
  • Factor V Leiden
  • Homocystinuria
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7
Q

Differentials for PE

A

pneumonia
Fall
Pneumothorax
Pleural effusion
Angina
MI
Pleurisy
Pericarditis

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8
Q

Symptoms of PE

A

Dyspnoea
Pleuritic chest pain
Cough
Haemoptysis
Dizziness
Syncope
Leg pain and swelling
Low-grade fever

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9
Q

What are the signs of PE?

A
  • Tachycardia(> 100 bpm)
  • Tachypnoea
  • Low grade fever(> 37.5º)
  • Hypoxia(sats < 94%)
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10
Q

What scoring system do you use to assess the likelihood, or risk, of PE?

A

Wells score

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11
Q

What Wells score makes PE likely? And what is the further management of this patient?

A

PE likely (score > 4)
straight to computed tomography pulmonary angiography (CTPA), if not available immediately, interim anticoagulation if safe.

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12
Q

What Wells score makes PE unlikely? And what is the further management of this patient?

A

PE unlikely (score ≤ 4): d-dimer blood test within four hours. If positive arrange CTPA. If negative, PE excluded consider alternative diagnosis.

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13
Q

What does the Wells score take into consideration?

A
  • Clinical symptoms and signs of DVT
  • PE is nr 1 diagnosis or equally likely
  • HR >100
  • Immobilisation at least 3 days or surgery in previous 4 weeks
  • Haemoptysis
  • Malignancy with treatment within 6 months or palliative
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14
Q

When is D-dimer used?

A

Only if low- moderate suspicion
Wells <= 4

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15
Q

What is the specificity, sensitivity and NPV of the d-dimer test?

A

Sensitivity= high
Negative predictive value = high
So you can rule out PE if negative

Specificity= low
lots of false positives

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16
Q

Disadvantages of CTPA?

A
  • Contrast may give AKI (not recommended if eGFR <30)
  • Allergy/anaphylaxis to iodine
  • Radiation
17
Q

CTPA (gold standard for diagnosis) - how fast should it be performed for massive and non-massive PE?

A

Massive PE= 1 hour
Non- massive = within 24 hours

18
Q

Investigations done in suspicion of PE

A

D-dimer
ECG
Bloods- FBC, UE, LFT, Coagulation screen, troponin, ABG
Imaging

19
Q

What imaging can be done in PE suspicion?

A

CXR- differentials
Lower limb ultrasound- DVT
CTPA
V/Q scan- in pregnancy or renal impairment or contrast allergy (if CTPA contraindicated)
ECHO: assessment of right ventricular strain/failure

20
Q

What is seen on an ECG with PE ?

A
  • Common: sinus tachycardia, non-specific ST or T wave abnormalities
  • Classical: S1Q3T3 pattern (deep S wave L1, Q wave in L3 and T wave inversion in L3)
  • Right heart strain: right bundle branch block, ST depression and T wave inversion anteriorly (V1-V4) and/or inferiorly (II, III, aVF)
21
Q

Supportive management of PE ?

A
  • ABCDE
  • Admission to hospital
  • Oxygen as required
  • Analgesia if required
  • Adequate monitoring for any deterioration
22
Q

Acute management: if in shock ?

A
  • Move to the resuscitation area of the emergency department or admitted to a (HDU)/(ITU)
  • Patients should be considered for thrombolysis therapy as per local guidelines
23
Q

When to give warfarin in PE as anticoagulation?

A

only for pt with lupus

24
Q

When is surgery indicated for PE Treatment?

A

where thrombolysis and anticoagulation is contradicted due to increased bleeding risk

25
Q

What surgical PE treatments are there?

A
  • Pulmonary embolectomy
  • percutaneous catheter-directed treatment
  • Patients who have repeat pulmonary embolisms, despite adequate anticoagulation, may be considered for inferior vena cava (IVC) filters.
26
Q

Complications

A
  • Massive PE - high mortality
  • Hypoxia due to V/Q mismatch
  • RV strain/failure/hypertrophy doe to rise in Pul artery pressure
  • Infection in poorly perfused lung
27
Q

In unprovoked PE: meaning no readily identifiable risk factor for VTE what do you think of ?

A

consider underlying malignancy or thrombophilia

28
Q

Initial treatment if PE likely before CTPA?

A

Anticoagulate the patient

29
Q

What are the choices of anti-coagulation?

A
  • DOAC
  • LMWH
  • Unfractionated heparin (shorter half-life)
  • Warfarin
30
Q

In a Stable pt, no renal impairment or co-morbidities: what anti-coagulation do you use?

A

offer apixaban/rivaroxaban (DOAC)
If not-suitable, LWMH for 5 days then offer edoxaban/warfarin

31
Q

Haemodynamicinstability (MASSIVE PE ) treatment ?

A

Unfractionated heparin (Treatment with heparins is not a contraindication to thrombolysis)

Consider Thrombolysis: IV alteplase (check for contraindications)

32
Q

Active cancer: what anti-coagulation do you use?

A

consider DOAC (e.g. edoxaban). If not suitable, LMWH.

33
Q

Renal impairment: what anti-coagulation do you use?

A

If creatinine clearance (CrCl) 15-50 ml/min-
offer apixaban/rivaroxaban or LMWH for 5 days then edoxaban/warfarin
If CrCl <15 ml/min
offer UFH(better for renal impairment) /LMWH followed by VKA

34
Q

Pt with antiphospholipid syndrome: what anti-coagulation do you use?

A

LMWH followed by a VKA should be used

35
Q

How long should anti-coagulation be continued in most patients?

A

3 months

36
Q

When is Thrombolysis indicated?

A
  • Cardiac arrest with confirmed or suspected PE
  • Confirmed PE with deterioration despite anticoagulation(i.e. worsening right ventricular strain, increasing oxygen requirements)
  • (MASSIVE PE) Haemodynamic instability(BP < 90 mmHg for > 15 minutes), AND
    • High clinical suspicious of PE
    • Confirmed PE within 14 days
36
Q

When is Thrombolysis indicated?

A
  • Cardiac arrest with confirmed or suspected PE
  • Confirmed PE with deterioration despite anticoagulation(i.e. worsening right ventricular strain, increasing oxygen requirements)
  • (MASSIVE PE) Haemodynamic instability(BP < 90 mmHg for > 15 minutes), AND
    • High clinical suspicious of PE
    • Confirmed PE within 14 days
37
Q

What are the absolute contraindications for thrombolysis?

A
  • Haemorrhagic stroke or ischaemic stroke <6 months
  • CNS neoplasia
  • Recent trauma or surgery
  • GI Bleed <1 month
  • Bleeding disorder
  • Aortic dissection
38
Q

What are the relative contraindications for thrombolysis?

A
  • Pt on Warfarin/ DOAC
  • Pregnancy
  • advanced liver disease
  • infective endocarditis

(ZUZ) Respiratory MED (21 decks)

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