Pulmonary Embolism Flashcards
What is Pulmonary Embolism
Pulmonary artery occlusion by an embolus
-Most likely form DVT
What is the pathology of PE
DVT Embolise and enters IVC to right heart
Pulmonary artery occlusion
Embolus = Pulmonary HTN = RV strain = Cor Pulmonale and RHF
What are the risk factors for PE
Virchow’s Triad sX
- Venous stasis (Immobility, Post surgery, AF)
- Hypercoagulability (Factor 5 leiden…)
- Endothelial damage (Smoking, Trauma, Catheters, HTN)
What are the presentations of PE
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Sudden SOB w/ Pleuritic chest pain w/ swollen painful leg (DVT)
Cough w/ haemoptysis (Streaky sputum)
Hypoxia
Dyspnoea and Tachypnoea
RHF Signs
What investigations may be used in PE
Bloods
-anaemia due to haemoptysis
-Raised CRP
Well’s Score >4+ = likely
D-Dimer - non specific but good NPV so can rule out negative PE
CXR = Fleischer, Hampton’s Hump and Westemarks
CTPA (GOLD)
Duplex US (if DVT suspected)
ECG = S1Q3T3, RBBB (Right axis deviation) and sinus tachycardia
What scoring system is used in PE
Well’s
3 points = DVT Signs
1.5 points = tachycardia, Immobility/surgery or Hx of DVT/PE
1 point = Haemoptysis and active cancer
What score on Well’s determines a D-Dimer test
<4
What tests should follow a Wells score greater than 4
CT Pulmonary Angiogram
LMWH
What is the initial management of PE
DR ABCDE
-Thrombolysis w/ alteplase in massive PE
What is the medical management of PE
1st line = Apixaban and Rivoroxaban (DOAC) DOAC CI = LMWH w/ Dabigatran
2nd line = Warfarin
IVC filter if anticoagulation CI
What should be administered in massive PE w/ Haemodynamic instability
Alteplase -> Catheter embolectomy
If Fail give catheter embolectomy
When is IV thrombolysis contraindicated
IC Haemmorhage Ischaemic stroke Head trauma Bleeding disorder -Offer Embolectomy if CI
What are the causes of hypercoagulability
Acquired -Pregancy and Obesity -Malignancy Inherited -Factor 5 leiden -Antiphospholipid syndrome -Protein C and S deficiency
What are the signs of RHF from PE
Hypotension
Tachycardia
Peipheral oedema
What does an ECG of PE show
S1Q3T3
RBBB w/ Right axis deviation
Sinus TACHYCARDIA
What does a chest xray of PE show
Fleisher rings (Enlarged Pul. Artery) Westermarks Signs (Hypovolemia) Hamptons (Wedge shaped lung)
CTPA is Gold standard for PE, what can be used if CTPA is Contraindicated
V/Q scan
What can be given for PE Prophylaxis
Compression stockings
Mobility
LMWH
What are the common factors included in Well’s score
DVT
Heart rate >100
Malignancy
Haemoptysis
At what wells score is PE likely
4 or more
If Wells score suggests unlikey PE, What is the next course
D Dimer
-Measure plasmin(clot burden)
-SENSITIVE
If >500ng/ml do CTPA
Describe a standard ECG found with PE
S1Q3T3
-S waves deep in L1
-Q waves very deep in L3
-T waves inverted in L3
what can be seen on doppler USS if a patient has DVT
Vein does not squeeze with compression
What prophylaxis can be offered in PE
Compression stockings
Increase mobility
LMWH
Describe the physiology of an occluded Pulmonary artery vessel
A-a gradient = 1
Low V/Q (Ventilation but no perfusion)
-Bronchoconstriction so Dyspnoea and smaller airways
What are the signs of Right heart fail
Hypotension
Tachcardia
Peripheral oedema
