Pulmonary Circulation

Question 1

Thrombus in pulmonary artery or branches. Not a disease itself but a cause of DVT.

Answer 1

Pulmonary embolism

Question 2

95% of PE’s arise from?

Answer 2

Lower extremities/pelvic DVT

Question 3

What is virchow’s triad?

Answer 3

Stasis, hypercoagulability, intimal damage

Question 4

What is the most common symptoms of a PE?

Answer 4

Dyspnea

Question 5

What is the most common sign of a PE?

Answer 5

Tachypnea

Question 6

What is the classic triad that a patient will give you in a history that should clue you in to a PE?

Answer 6

Dyspnea
Pleuritic chest pain
Hemoptysis

Question 7

Post-op patient with sudden tachypnea, tachycardic, apprehensive and complaining of pleuritic chest pain, with hemoptysis and cough

Answer 7

Classic presentation of a patient with a PE

Question 8

If there is a massive PE, what will the symptoms be?

Answer 8

Syncope, hypotension, pulseless electrical activity

Question 9

What is a predisposing condition to a PE?

Answer 9

Factor V Leiden

Question 10

____% of patients with a DVT will have a PE

Answer 10

50

Question 11

Is the PE on a patient with a pulmonary embolism usually normal?

Answer 11

Yes! Could have rales or pleural friction rub, but usually unremarkable

Question 12

What special test may be positive on a patient with a PE?

Answer 12

Homan’s sign test (Calf pain with dorsiflexion)

Question 13

What does the CXR NORMALLY look like on a patient with a PE?

Answer 13

Normal! If you have a normal CXR in a setting of highly suspicious hypoxia, be suspicious!

Question 14

Pleural effusion and atelectasis are two things that could be seen on a CXR on a patient with ___ ___

Answer 14

Pulmonary embolism

Okay, I gave that one to you

Question 15

What are the classic, but less common, signs of a PE?

Answer 15

Westermark’s sign
Hamptom’s Hump
Abrupt cut off vessels

Question 16

Avascular markings distal to area of embolus

Answer 16

Westermarks’ sign

Question 17

Wedge-shaped infiltrate

Answer 17

Hampton’s hump

Question 18

What are the most common ECG findings on a patient with a PE?

Answer 18

Sinus tachycardia with nonstop ST/T changes

Question 19

What will the ABG on a patient with a PE be initially?

Answer 19

Respiratory alkalosis

Question 20

What will the ABG on a patient with a PE be over time?

Answer 20

Respiratory acidosis; increase in A-a gradient

Question 21

Is a D dimer useful in diagnosing a PE?

Answer 21

It is helpful if it is negative but nonspecific if it is positive

Question 22

What is the gold standard to diagnose a PE?

Answer 22

Pulmonary angiography (usually only done if high suspicion and negative CT or VQ scan)

Question 23

What is the initial screening test for a PE?

Answer 23

Helical CT scan

Question 24

Why should you use a doppler ultrasound to help diagnose a PE?

Answer 24

70% of patients with PE have + lower extremity (DVT)

Question 25

If veins are non compressible on ultrasound, what does that mean?

Answer 25

+ for DVT

Question 26

If you have a patient with a PE and they are hemodynamically stable, what are your two options?

Answer 26

UFH or LMWH and PO warfarin

OR

IVC filter if anticoagulation contraindicated

Question 27

If you have a patient with a PE and they are hemodynamically Unstable, what are your two options?

Answer 27

Thrombolytic tx

OR

Embolectomy if anticoagulation contracindicated

Question 28

Why do you treat PEs with heparin?

Answer 28

To prevent further emboli rather than treat the existing one

Question 29

Is the first PE usually the most deadly?

Answer 29

No, usually the first episode doesn’t kill, subsequent PEs are more deadly

Question 30

What do you have to monitor when dosing unfractioned heparin?

Answer 30

PTT

Question 31

If you give LMWH, do you have to monitor PTT?

Answer 31

No

Question 32

How long should a patient be on warfarin for an initial DVT?

Answer 32

3-6 months

Question 33

What pathway does warfarin work with?

Answer 33

Extrinsic II, VII, IX, X, protein C and S

Question 34

What is the antidote for heparin toxicity?

Answer 34

Protamine sulfate

Question 35

What can you use for thrombolysis of a clot?

Answer 35

Altepase (tPA), streptokinase, urokinase

Question 36

When should you use altepase, or another thromolysis drug on a patient with a PE?

Answer 36

For a massive PE or hemodynamic compromise in which anticoagulation is contraindicated

Question 37

When is thrombolysis contraindicated?

Answer 37

Internal bleed or CVA w/in 2 months

Question 38

When should you perform a thrombectomy or embolectomy?

Answer 38

Massive/unstable PE or if thrombolysis is ineffective

Question 39

What ist he most important step in managing a PE?

Answer 39

Prophylaxis!

Question 40

Who is prophylaxis warranted in?

Answer 40

Pre op in patients undergoing surgery with prolonged immobilization, pregnant women, or history of prior DVT/PE

Question 41

What are some non-invasive ways to help your patients prevent blood clots

Answer 41

Ambulation, elastic stockings, pneumatic compression devices/venodyne boots

I used to have to do all of these with my patients and putting TED stockings on is a fate worse than death.

Question 42

What is the third leading cause of death in hospitalized patients?

Answer 42

PE.. but you never could’ve guessed that

Question 43

What heart sound will be accentuated in a patient with a PE?

Answer 43

The second sound (S2)

Question 44

What ECG pattern is classic for a PE, and shows cor pulmonae?

Answer 44

S1Q3T3

Question 45

What are the three most common places to get a DVT

Answer 45

Iliofemoral vein
Popliteal vein
Pelvic vein