Pulmonary Circulatory Disorders

Question 1

What is the first symptom of PE in 25% patients?

Answer 1

Sudden death

50% are never diagnosed

Question 2

The blockage of a main artery of the lung, or one of its branches, by a substance that has traveled elsewhere in the body through the bloodstream

Answer 2

Pulmonary Embolus (PE)

Question 3

Blood clot from a systemic vein through the right side of the heart to the pulmonary circulation.

Answer 3

Venous thromboembolism

Question 4

Where do PEs usually start?

Answer 4

Lower extremities (DVTs, but rarely from calf)
upper extremities are rare (catheters or pacing wires

Question 5

What factors contribute to clot formation?

Answer 5

Virchow’s triad:
Venous Stasis
Hypercoagulability
Injury to a vessel wall

Question 6

What are the types of pulmonary emboli?

Answer 6

(FAT BAT)

Fat, Air, Thrombus, Bacteria, Amniotic fluid, Tumor

Question 7

How is a DVT diagnosed?

Answer 7

Duplex Ultrasound

Question 8

What sign is it when you flex your foot and get calf pain?

Answer 8

Homan’s sign

Question 9

What are the classic symptoms of PE?

Answer 9

Triad: (Sudden dyspnea, pleuritic chest pain, hemoptysis)
Tachypnea (seen more often than hemoptysis)
Anxiety, Lightheadedness, Low blood pressure

Question 10

What might you see on a physical exam in a PE?

Answer 10

Nonspecific signs...
Tachycardia/Tachypnea
Various lung sounds
Increased pulmonic component of 2nd heart sound
Right sided S3 or S4
JVD
Pain/Edema of lower extremity (thrombus)
*Mild to moderate hypoxemia with low PaCO2*

Question 11

What signs in a ventilated patient would concern you of a PE (until proven otherwise!)?

Answer 11

sudden onset of hypotension, tachycardia, or hypoxia

Question 12

What criteria help determine the probability of a PE?

Answer 12

The Wells criteria

Question 13

How do ECG changes help diagnose PE?

Answer 13

They are generally nonspecific, though often (70%) abnormal.
Commonly Sinus tachy, non specific ST and T wave changes
T wave inversion in anterior leads (V1-V4)
S1Q3T3

Question 14

Describe S1Q3T3.

Answer 14

Prominent S in Lead I
Q wave in Lead III
T wave inversion in Lead III
(seen in both PE and Cor Pulmonale)

Question 15

What finding will you see most often in an ABG with a PE?

Answer 15

Respiratory alkalosis

Question 16

How specific is a D-Dimer test with PE?

Answer 16

Not very, but it can tell you if a PE DIDN’T happen (good negative predictor value)

Question 17

What most common signs will you see in a chest xray for a PE?

Answer 17

Still nonspecific, but:
Pleural effusion
Atelectasis

Question 18

What is a prominent central pulmonary artery with local oligemia on an xray?

Answer 18

Westermark sign (difficult to see)

Question 19

What is a pleural based area of increased opacity that represent intraparenchymal hemorrhage?

Answer 19

Hampton hump

Question 20

What is becoming the new test of choice for PE?

Answer 20

CT pulmonary angiogram (75-95% sensitive)

Question 21

What precautions must you take with a CT pulmonary angiogram?

Answer 21

It uses dye, so you must not be allergic to the dye.

Question 22

What does a V/Q scan show?

Answer 22

Absence of perfusion to occluded areas, and Absence of ventilation to blocked areas.

Question 23

What test is used most prominently to detect a proximal DVT?

Answer 23

Venous ultrasound

Question 24

How many PE patients will have a DVT on ultrasound?

Answer 24

70%

Question 25

If positive for a DVT on ultrasound, how do you proceed?

Answer 25

Treat them for a PE

Question 26

What is the most definitive test for PE?

Answer 26

Pulmonary Angiography

but it is very invasive

Question 27

What is the initial treatment of a PE?

Answer 27

Supportive
Oxygen
Analgesics
Meds to maintain BP

Question 28

How long should a patient be treated with anticoagulants with a PE?

Answer 28

3 months (if first episode and provoked)
6-12mo extended therapy unprovoked or recurrent with low/mod risk of bleeding
Indefinite with nonreversible risk factors

Question 29

What additional measures can be taken to treat a PE?

Answer 29

IVC filter (to catch a clot in the IVC)
Pulmonary embolectomy (emergency procedure, last resort)

Question 30

What are signs of pulmonary hypertension?

Answer 30

Dyspnea
Dull, retrosternal chest pain (resembles angina)
Fatigue/syncope on exertion
Cardiac sounds

Question 31

How do you treat pulmonary hypertension?

Answer 31

Primary: Meds, lung transplant.
Secondary: Treat the underlying condition…