Pulmonary embolism

Question 1

PE symptoms

Answer 1

Pleuritic chest pain
Dyspnoea
Haemoptysis
Tachycardia
Tachypnoea
Respiratory crackles
Fever

Question 2

Well’s score criteria

Answer 2

Signs of DVT +3
Most likely diagnosis +3
HR > 100 +1.5
Immobilised +1.5
Previous DVT/PE + 1.5
Haemoptysis +1
Cancer +1

PE likely > 4 points -> arrange CTPA (VQ scan if renal failure or pregnant), if delay give DOAC.
PE unlikely < 4 points -> D-dimer
D-dimer positive then CTPA and DOAC
D-dimer negative- unlikely, stop DOAC

Question 3

ECG in a PE

Answer 3

S1Q3T3 pattern
Large S in lead I
Large Q in lead III
Inverted T wave in lead III

RBBB
Right axis deviation
Sinus tachycardia

Question 4

Management of stable PE

Answer 4

1st line: DOAC e.g. apixaban or rivaroxaban

Alternative: LMWH + dabigatran/warfarin
LMWH/Unfractionated heparin + warfarin if severe renal impairment eGFR <15

Anticoagulation for at least 3 months, continued to 6 months if unprovoked.

Question 5

Management of unstable PE

Answer 5

Thrombolysis e.g. with altepase 10mg IV