Pulmonary Embolism

Question 1

What is Pulmonary Embolism

Answer 1

Pulmonary artery occlusion by an embolus

-Most likely form DVT

Question 2

What is the pathology of PE

Answer 2

DVT Embolise and enters IVC to right heart
Pulmonary artery occlusion
Embolus = Pulmonary HTN = RV strain = Cor Pulmonale and RHF

Question 3

What are the risk factors for PE

Answer 3

Virchow’s Triad sX

• Venous stasis (Immobility, Post surgery, AF)
• Hypercoagulability (Factor 5 leiden…)
• Endothelial damage (Smoking, Trauma, Catheters, HTN)

Question 4

What are the presentations of PE

Answer 4

~~~
Sudden SOB w/ Pleuritic chest pain w/ swollen painful leg (DVT)
Cough w/ haemoptysis (Streaky sputum)
Hypoxia
Dyspnoea and Tachypnoea
RHF Signs

Question 5

What investigations may be used in PE

Answer 5

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

Question 6

What scoring system is used in PE

Answer 6

Well’s
3 points = DVT Signs
1.5 points = tachycardia, Immobility/surgery or Hx of DVT/PE
1 point = Haemoptysis and active cancer

Question 7

What score on Well’s determines a D-Dimer test

Answer 7

<4

Question 8

What tests should follow a Wells score greater than 4

Answer 8

CT Pulmonary Angiogram

LMWH

Question 9

What is the initial management of PE

Answer 9

DR ABCDE

-Thrombolysis w/ alteplase in massive PE

Question 10

What is the medical management of PE

Answer 10

1st line = Apixaban and Rivoroxaban (DOAC) DOAC CI = LMWH w/ Dabigatran
2nd line = Warfarin
IVC filter if anticoagulation CI

Question 11

What should be administered in massive PE w/ Haemodynamic instability

Answer 11

Alteplase -> Catheter embolectomy

If Fail give catheter embolectomy

Question 12

When is IV thrombolysis contraindicated

Answer 12

IC Haemmorhage
Ischaemic stroke
Head trauma
Bleeding disorder
-Offer Embolectomy if CI

Question 13

What are the causes of hypercoagulability

Answer 13

Acquired
-Pregancy and Obesity
-Malignancy
Inherited
-Factor 5 leiden
-Antiphospholipid syndrome
-Protein C and S deficiency

Question 14

What are the signs of RHF from PE

Answer 14

Hypotension
Tachycardia
Peipheral oedema

Question 15

What does an ECG of PE show

Answer 15

S1Q3T3
RBBB w/ Right axis deviation
Sinus TACHYCARDIA

Question 16

What does a chest xray of PE show

Answer 16

Fleisher rings (Enlarged Pul. Artery)
Westermarks Signs (Hypovolemia)
Hamptons (Wedge shaped lung)

Question 17

CTPA is Gold standard for PE, what can be used if CTPA is Contraindicated

Answer 17

V/Q scan

Question 18

What can be given for PE Prophylaxis

Answer 18

Compression stockings
Mobility
LMWH

Question 19

What are the common factors included in Well’s score

Answer 19

DVT
Heart rate >100
Malignancy
Haemoptysis

Question 20

At what wells score is PE likely

Answer 20

4 or more

Question 21

If Wells score suggests unlikey PE, What is the next course

Answer 21

D Dimer
-Measure plasmin(clot burden)
-SENSITIVE
If >500ng/ml do CTPA

Question 22

Describe a standard ECG found with PE

Answer 22

S1Q3T3
-S waves deep in L1
-Q waves very deep in L3
-T waves inverted in L3

Question 23

what can be seen on doppler USS if a patient has DVT

Answer 23

Vein does not squeeze with compression

Question 24

What prophylaxis can be offered in PE

Answer 24

Compression stockings
Increase mobility
LMWH

Question 25

Describe the physiology of an occluded Pulmonary artery vessel

Answer 25

A-a gradient = 1
Low V/Q (Ventilation but no perfusion)
-Bronchoconstriction so Dyspnoea and smaller airways

Question 26

What are the signs of Right heart fail

Answer 26

Hypotension
Tachcardia
Peripheral oedema