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.
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PE. Hemorrhage from the infarcted lung is also thought to be responsible for hemoptysis.
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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.
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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
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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
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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.
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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).
PE. what is the best test that we commonly use for the diagnosis?
CT angiography with IV contrast.
PE. If renal insufficiency (GFR <30ML/MIN) and normal CXR, morbid obesity, and contrast allergy? what test to do?
V/Q scan.
PE. treatment? 1 –> 2
Anticoagulation –> heparin or IVC filter.
PE. treatment. when start warfarin?
Heparin (bridge) warfarin. Once we reach a goal PTT >1.5-2 times normal–> warfarin is initiated.
PE. treatment. what use in kidney insuff?
Unfractionated heparin used in renal insufficiency.
PE. treatment. other options for anticoagulation to unfr heparin?
LMWH, rivaroxaban and fondaparinux are other options.
PE. treatment. why rivaroxaban does not require bridging?
Rivaroxaban does not require heparin bridging due to immediate onset of action (unlike warfarin).
PE. treatment. Heparin> NOAC in what patients?
Heparin > NOAC in cancer patients due to a possible increased risk of malignancy-related bleeding with direct oral anticoagulants.
PE. treatment. IVC filter - when?
Contraindicated anticoagulation and DVT.
PE. treatment. IVC filter. amboss situation:
Patient 4 days post- craniotomy due to brain bleed presents with DVT, best next step? IVC filter.
PE. treatment. when tPA?
tPA is used in massive pulmonary embolism: elevated troponin or hemodynamic instability
PE. treatment. embolectomy?
Embolectomy: last resort.
PE. PROGNOSIS: Low oxygen saturation and AF are associated with poor prognosis in PE.
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CT pulmonary angiogram (CTPA) is the imaging modality of choice.
PE. diagnostic strategy algo.
Wells –> PE unlikely –>?
do d dimers
PE. diagnostic strategy algo.
Wells –> PE unlikely –> d dimers =< 500 ->?
PE excluded
PE. diagnostic strategy algo.
Wells –> PE unlikely –> d dimers > 500 ->?
Do CTPA
PE. diagnostic strategy algo.
Wells –> PE ikely –>?
CTPA
PE. diagnostic strategy algo.
PE likely
or PE unlikely + >500 di dimers
DO CTPA –>?
Negative –> PE excluded
positive –> PE confirmed
PE. suspected PE. didelis algo.
Stabilize + O2 –> evaluate contraindications for anticoagulation.
There is contraindication –>?
Obtain diagnostic test to evaluate for PE
PE. suspected PE. didelis algo.
contraindications for anticoagulation –> diagnostic test –> positive for PE –>?
Consider IVC filter
PE. suspected PE. didelis algo.
contraindications for anticoagulation –> diagnostic test –> negative for PE –>?
no further evaluation needed
PE. suspected PE. didelis algo.
Stabilize + O2 –> NO contraindications for anticoagulation –>?
Assess clinical suspicion of PE with modified wells –> likely/unlikely PE.
PE. suspected PE. didelis algo.
NO contraindications for anticoagulation –> PE likely –>?
Consider anticoagulation, especially if patient has: no relative contraindications
Moderate to severe distress
PE. suspected PE. didelis algo.
NO contraindications for anticoagulation –> PE unlikely –>?
Obtain diagnostic test to evaluate for PE
PE. suspected PE. didelis algo.
NO contraindications for anticoagulation –> PE likely –> Consider anticoagulation –>
following is the same step as for PE unlikely, ie. Obtain diagnostic test for PE.
PE. suspected PE. didelis algo.
NO contraindications for anticoagulation –> —> –> diagnostic test– > Negative for PE?
stop anticoagulation
PE. suspected PE. didelis algo.
NO contraindications for anticoagulation –> —> –> diagnostic test– > Positive for PE?
start of continue anticoagulation;
consider surgery or thrombolytics if indicated
If PE likely –> CTPA inconclusive –> ?
Do V/Q scan
PE. D-dimers.
D-dimer – An elevated D-dimer alone is insufficient to make a diagnosis of PE, but a normal D-dimer can be used to rule out PE in patients with a low or intermediate probability of PE.
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PE. Low prob. + D-dimer =< 500–>?
excluded PE
PE. Low prob. + D-dimer > 500–>?
do CTPA
PE. Intermediate prob. + D-dimer < 500–>?
it effectively excludes PE, and typically no further testing is required.
BUT
Some experts will proceed with diagnostic imaging in select patients. For example, imaging may be considered in patients who have limited cardiopulmonary reserve (ie, patients in whom PE would not be well tolerated) or those in whom the clinical probability of PE was in the upper zone of the intermediate range (eg, a Wells score of 4 to 6 or a Geneva score of 8 to 10).
PE. Intermediate prob. + D-dimer > 500–>?
do CTPA.
PE. High prob. + D-dimer < 500–>?
normal D-dimer is not as helpful for excluding the diagnosis and does not need to be performed.
negative D-dimer result does reduce the likelihood of PE in this population, it does not reduce it sufficiently to rule out the diagnosis.
Always do CTPA in high risk patients
PE. CTPA - what findings confirm PE?
CTPA showing a filling defect confirms the diagnosis of PE.
PE. CTPA - what findings exclude PE?
A negative CTPA indicates that the likelihood of PE is low.
PE. CTPA –> when do V/Q scan?
An inconclusive CTPA result may necessitate alternate imaging, such as V/Q scanning or lower-extremity venous ultrasonography.
PE. V/Q scan when?
V/Q scan mostly reserved for patients in whom CTPA is contraindicated or inconclusive, or when additional testing is needed.
PE. leg vein UG, when?
can be used as an initial test in the evaluation of suspected PE, as positive results can justify initiating anticoagulant treatment. However, because of the low sensitivity of Doppler ultrasonography in this setting, it is not sufficient to rule out PE.
Catheter-based pulmonary angiography — Pulmonary angiography, in which contrast is injected under fluoroscopy via a catheter introduced into the right heart, was the historical gold standard for the diagnosis of PE. With the widespread emergence of CTPA, this procedure is infrequently used and reserved for rare circumstances for patients with a high clinical probability of PE, in whom CTPA or V/Q scanning is nondiagnostic and in whom a diagnosis determines an important clinical decision (eg, an intervention) (image 4).
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Magnetic resonance pulmonary angiography — MRPA is not recommended as a first-line test for the diagnosis of PE but may be an imaging option for diagnosis of PE in patients in whom neither CTPA nor V/Q scan can be performed.
Diagnosis – A diagnosis of PE is made radiographically based upon CTPA.
uptd. HD stable. anticoagulation
contraindicated –> PE confirmed?
IVC filter
uptd. HD stable. anticoagulation
contraindicated –> PE excluded?
no further evaluation
uptd. HD stable. anticoagulation indicated –> evaluate PE probability pagal wells –> empiric anticoagulation according to probability and time that will require to do diagnostic test. Low probab and time?
Low probability.
Will diagnostic test take longer than 24h?
Yes -> give anticoag
No -> dont give
uptd. HD stable. anticoagulation indicated –> evaluate PE probability pagal wells –> empiric anticoagulation according to probability and time that will require to do diagnostic test. intermediate Will diagnostic test take longer than 4h?probab and time?
Intermediate
Will diagnostic test take longer than 4h?
Yes -> give anticoag
No -> dont give
uptd. HD stable. anticoagulation indicated –> evaluate PE probability pagal wells –> empiric anticoagulation yes/no –> do diagnostic test –> PE excluded?
stop anticoagulation and seek other causes
uptd. HD stable. anticoagulation indicated –> evaluate PE probability pagal wells –> empiric anticoagulation yes/no –> do diagnostic test –> PE confirmed –> ?
Does clinical severity warant consideration of thrombolysis?
uptd. HD stable.
Does clinical severity warant consideration of thrombolysis –> no ->?
Initiate/continue anticoagulation.
uptd. HD stable.
Does clinical severity warant consideration of thrombolysis –> yes ->?
thrombolytic therapy contraindicated?
uptd. HD stable.
Does clinical severity warant consideration of thrombolysis –> yes -> thrombolytic therapy IS contraindicated –>?
Surgical or catheter embolectomy
uptd. HD stable.
Does clinical severity warant consideration of thrombolysis –> yes -> thrombolytic therapy IS NOT contraindicated –>?
Hold anticoagulation, administer thrombolytics, then resume anticoagulation
uptd. HD stable.
After thrombolysis –> clinical improvement/no improvement –>?
Improvement –> continue anticoagulations
No improvement –> surgical or catheter embolectomy.
uptd. HD unstable. bandyti stabilizuoti ,,resusitation” resp and cardiac. –> still unstable –> daryt kardio echo –> jeigu RV impairment –> kardu gaires sako kad CT reik daryt, nu tai mes su echo nezaistume blet. –> Rv over load –> thrombolysis contraindiated –>?
Surgical or catheter directed embolectomy
uptd. HD unstable. bandyti stabilizuoti ,,resusitation” resp and cardiac. –> still unstable –> daryt kardio echo –> jeigu RV impairment –> kardu gaires sako kad CT reik daryt, nu tai mes su echo nezaistume blet. –> Rv over load –> thrombolysis indiated (,,non contraindicated) –>?
Hold anticoagulation –> adminiter thrombolytics –> resume anticoagulation
uptd. HD unstable. bandyti stabilizuoti ,,resusitation” resp and cardiac. –> still unstable –> daryt kardio echo –> jeigu RV impairment –> kardu gaires sako kad CT reik daryt, nu tai mes su echo nezaistume blet. –> Rv over load –> thrombolysis indiated (,,non contraindicated) –>thrombolysis –> clinical improvement/nonimprovement –?
improvement –> continue anticoagulation
No improvement –> repeat systemic thrombolysis, surgical or catheter directed embolectomy
What is Massive PE?
PE complicated by hypotension and/or right heart strain.
Massive PE. presentation?
a. Syncope
b. Obstructive shock
c. Pleuritic chest pain
d. Tachycardia
e. Tachypnea
Massive PE. what would show right heart catheterization?
a. incr. right atrial pressure
b. incr. pulmonary artery pressure
c. Normal PCWP
Massive PE. metabolic?
Hypercapnia, respiratory, and/or lactic acidosis are uncommon but can be seen in patients with massive PE associated with obstructive shock and respiratory arrest.
Massive PE. yra schema pathophysiology.
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Fat embolism. etiology? 3
Fracture of marrow-containing bone (eg femur)
Orthopedic surgery
Pancreatitis
Fat embolism. clinical presentation. onset?
24-72 hours following inciting vent
Fat embolism. clinical presentation. triad?
Respiratory distress
Neurologic dysfunction (eg confusion)
Petechial rash
Fat embolism. diagnosis?
Based on clinical presentation
Fat embolism. prevention and treatment? 2
Early immobilization of fracture
Supportive care (eg mechanical ventilation)
Venous air embolism. Etiology? 3
Trauma, certain surgeries (eg neuro)
Central venous catheter manipulation
Barotrauma (eg Positive pressure ventilation)
Venous air embolism. clinical?
Sudden onset respiratory distress
Hypoxemia, obstructive shock, cardiac arrest
Venous air embolism. management?
Left lateral decubitus positioning
High flow or hyperbaric oxygen
Venous air embolism.
Deep underwater diving (scuba) is associated with risk of decompression sickness (the bends).
Due to nitrogen gas bubbles that form when a diver ascends too rapidly.
Usually after 12 hours of surfacing.
Venous air embolism.
lodge in skin capillaries –> symptoms?
pruritis, mottling, and cyanosis.
Venous air embolism.
lodge in pulmonary capillaries?
respiratory distress and pulmonary edema.
Venous air embolism.
what is large volume?
Large volume of coalesced air can lodge in the RVOT and cause obstructive shock.
Venous air embolism.
can cross to arterial circulation. what symptoms?
Can cross to the arterial circulation:
Brain –> confusion, gait ataxia, and dysarthria.
A small volume of coalesced air can cause localized stroke or MI.
Venous air embolism. management? 3
Management: IV hydration. Trendelenburg position. Administration of 100% of oxygen.
Pulmonary infarction. can occur due to acute PE.
presentation?
Chest pain, dyspnea, mild fever and leukocytosis, hemoptysis
Pulmonary infarction.
diagnosis? 3
a. Chest X-ray: Hampton hump
b. CT scan: Wedge-shaped, pleural based opacification
c. CT with contrast: Filling defect in pulmonary artery due to pulmonary embolism.
Pulmonary infarction.
differentials?
- Differentials:
a. Bacterial Pneumonia: Alveolar infiltrates are not wedge-shaped, as they follow bronchial rather than vascular distribution; Hemoptysis can occur, but is uncommon
b. Lung Cancer: i. Imaging shows a rounded or spiculated mass
c. Pneumocystis Pneumonia: Seen in HIV patients (CD4+ counts < 200/mm3); Imaging shows a diffuse interstitial pattern
d. TB: i. Imaging shows cavitary lesions
Pulmonary infarction.
4. Note: Pulmonary embolism is a common cause of both transudative and exudative pleural effusion.
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