Pulmonary Embolism

Question 1

What clinical features are seen?

Answer 1

• chest pain - typically pleuritic
• dyspnoea + tachypnoea
• tachycardia
• haemoptysis

Question 2

1. What test can be used to help rule out PE?
2. a) When should this test be used?
   b) What does a negative score mean?

Answer 2

1. pulmonary embolism rule out criteria
2. a) if person has <15% of PE
   b) <2% chance of PE

Question 3

PE Diagnosis

1. Describe the investigation route for if you suspect PE?
2. What should you do if CTPA negative?

Answer 3

1. if Wells criteria > 4 arrange immediate CTPA

if wells criteria 4 or less arrange D-Dimer test
- if positive arrange immediate CTPA

NOTE: if any delays in investigations give a DOAC in the interim and then stop if PE no longer suspected

2. perform proximal leg vein US to loom for DVT

Question 4

PE ECG

1. What is the most common ECG finding?
2. What other characteristics can be seen on ECG?

Answer 4

1. sinus tachycardia
2. • S1Q3T3
   • RBBB
   • RAD

Question 5

What can be missed on CTPA for PE?

Answer 5

peripheral emboli affecting subsegmental arteries

Question 6

When is a V/Q scan the investigation of choice over CTPA?

Answer 6

renal impairment (as V/Q doesn’t require contrast)

Question 7

PE management

1.

a) What is the treatment of choice if patient is haemodynamically stable?
b)
i) When would this not be the case?
ii) What is the treatment of choice in this instance?

2. How long should patients stay on anticoagulation if the PE was:
   a) provoked (e.g. following major surgery)
   b) unprovoked
3. How is a PE managed if the patient is haemodynamically unstable?
4. What is considered in repeat PEs?

Answer 7

1. a) apixaban or rivaroxaban

b)
i)
- apixaban or rivaroxaban not suitable
- severe renal impairment
- triple positive antiphospholipid syndrome
ii) LMWH followed by vitamin K antagonist (warfarin)
(If apixaban or rivaroxaban simply not suitable can also follow up LMWH with edoxaban or dabigatran)

2

a) 3 months (as this event seen as transient and patient no longer at risk)
b) 6 months

3. thrombolysis
4. IVC filter