Pulmo. PE + pulm infarct (09-29) (1) Flashcards
PE. Etiology? 3
DVT (Virchow’s triad).
Fat.
Amniotic fluid, tumor, bacterial, air.
PE. pathophysiology?
Infarct and inflammation → pleuritic chest pain→ hemoptysis → surfactant dysfunction → atelectasis → PaO2 down.
PE. Hyperventilation due to pain –> ?
decreased CO2
PE. V/Q, A-a?
V/Q mismatch, elevated A-a gradient.
PE. blockage of pulmonary artery –>?
Elevated pulmonary artery pressure due to blockage→ increased RV afterload → forward failure with decreased CO.
PE. 3 most common symptoms?
acute-onset dyspnea (73%),
pleuritic chest pain (66%),
tachypnea (54%).
PE. other, less common symptoms?
Hemoptysis (13%), symptoms of DVT (Calf or thigh swelling, erythema, edema, tenderness, palpable cords), tachycardia (24%), low-grade fever.
Сough (37 %)
PE. what are DVT symptoms?
Calf or thigh swelling, erythema, edema, tenderness, palpable cords
PE. Wedge infarct –> 2
hemoptysis (20%) and chest pain (66%).
PE. breath sounds? 2
Rales (18%);
Decreased breath sounds (17%)
PE. Pleuritic pain is typical in this population due to inflammation of the pleura.
.
PE. Hemorrhage from the infarcted lung is also thought to be responsible for hemoptysis.
.
PE. Pulmonary hypertension –> 2?
Right heart strain. Distended JVD
PE. syncope indicates what?
massive PE
PE. low oxygenation shows what?
assoc with poor prognosis.
PE. what metabolic change?
Hypocarbia. Respiratory alkalosis
Hypercapnia, respiratory, and/or lactic acidosis are uncommon but can be seen in patients with massive PE associated with obstructive shock and respiratory arrest.
PE. 2 murmurs?
Possible murmurs: tricuspid regurgitation and split second heart sound (delayed closure of pulmonary valve due to high pressure).
PE. why may occur bilateral wheezing?
Bilateral wheezing can occur in acute PE due to cytokine-induced bronchoconstriction in response to hypoxia and infarction
PE. in what proc. occur HD collapse?
Hemodynamic collapse and syncope < 10 proc. each.
PE. hoarseness mechansim?
Hoarseness from a dilated pulmonary artery is a rare presentation (Ortner syndrome)
PE. CBT and chemistries findings?
leukocytosis, incr. ESR, elevated serum lactate and LDH, incr. AST.
PE. kidney labs?
Creatinine and eGFR helps determine the safety of administering contrast for angiography.
PE. tropinin?
useful prognostically but not diagnostically.
As markers of right ventricular dysfunction, troponin levels are elevated in 30 to 50 percent of patients who have a moderate to large PE and are associated with clinical deterioration and death after PE.
PE. ABG?
Hypoxemia (74 percent)
Widened alveolar-arterial gradient for oxygen (62 to 86 percent)
Respiratory alkalosis and hypocapnia (41 percent)
PE. xray aim?
Typically performed in most patients suspected of PE to look for an alternative cause of the patient’s symptoms.
Usually normal unless you have a wedge infarct.
PE. xray. What is Hampton hump?
peripheral wedge of lung opacity due to pulmonary infarction.
PE. xray. What is Westermark sign?
peripheral hyperlucency due to oligemia.
PE. xray. What is Fleischner sing?
enlarged pulmonary artery.
PE. ECG. Most common finding?
Sinus tachycardia is a more common finding + nonspecific ST-segment and T-wave changes.
PE. ECG. what abbreviation?
S1Q3T3.
Prominent S in lead I,
Q in lead III,
and inverted T in lead III.
PE. ECG - also RBBB.
.
PE. ECG. what finding assoc with poor prognosis?
Afib
PE.
Uptd: ECG abnormalities that are associated with a poor prognosis in patients diagnosed with PE include: Atrial arrhythmias (eg, atrial fibrillation), Bradycardia (<50 beats per minute) or tachycardia (>100 beats per minute); New right bundle branch block; Inferior Q-waves (leads II, III, and aVF); Anterior ST-segment changes and T-wave inversion S1Q3T3 pattern
.
PE. cardioecho?
dilated RV cavity and tricuspid regurgitation.
Venous reflux with dilatation of IVC, liver congestion.
PE. Lower extremity duplex ultrasound.
If symptoms of DVT or CI to CTPA.
Supportive: hypoechoic material in lumen of veins.
Venous lumens do not collapse under compression.
Negative US doesn’t rule out PE.
PE. most definitive diagnostic method?
CTPA: Most definitive diagnostic test.
PE. CTPA contraindications?
Contraindications: pregnancy, contrast allergy, renal insufficiency.
PE. CTPA what is seen?
Visible intraluminal filling defect of pulmonary arteries.
Wedge-shaped infarctions with pleural effusion is pathognomonic.
PE. V/q scan?
what is seen and for what patients?
Alternative to CTPA if CI.
Perfusion failure in normally ventilated pulmonary area.
Useful for those who have contrast allergy, renal impairment, or morbid obesity.
PE. Pulmonary angiography. how is performed, for what purpose?
Insert catheter into right heart and pulmonary artery and inject catheter.
Usually just to guide endovascular treatment.
Not used because invasive and more difficult than CTPA.
PE. Wells m. +3 points? 2
Clinical signs of DVT
Alternate diagnosis less likely than PE
PE. Wells m. + 1,5 points? 3
Previous PE or DVT
HR > 100
Recent surgery or immobilization
PE. Wells m. + 1 point?2
Hemoptysis
Cancer
PE. Wells m. Total score?
=< 4 points - PE unlikely
>4 point - PE likely
PE. Wells.
Modified - 4 points more/less
Non modified -
<2; 2-6; >6 points. same scale
.
PE. Wells.
Immobilization how long?
> =3 days
PE. Wells. Surgery within what period?
within last 4 weeks
PE. Wells. Long-distance flights, although a risk factor for VTE, do not qualify as immobilization per Wells criteria.
.
PE. Wells.
<2 points. what to evaluate in this case?
<2: not a PE.
Get a D-dimer to definitely rule it out; it has a negative predictive value.
PE. Wells. <2: not a PE.
Do D-dimer. If > 500?
CTPA or V/Q scan.
In patients with high pretest probability –> d-dimer result is unreliable in excluding VTE.
In patients with low pretest probability -> it reliably excludes it.
PE. Wells. <2: not a PE.
Do D-dimer. If < 500?
other cause.
PE. Wells.
> /=4 on CT scan or >/=6 on V/Q scan or unstable patient.
what to do?
Start heparin.
CT angiography with IV contrast: best test. Pulmonary angiogram is the gold standard. (don’t pick it on test)
If renal insufficiency (GFR <30ML/MIN) and normal CXR, morbid obesity, and contrast allergy: V/Q scan.
PE. Gold standard for diagnosis?
Pulmonary angiogram is the gold standard. (don’t pick it on test).