Pulmonary Embolism

Question 1

What is a pulmonary Embolism

Answer 1

Common, serious, potentially fatal blockage within the pulmonary circulation.

Question 2

Why do <10% of patients with fatal emboli receive treatment for the condition?

Answer 2

It’s not recognized.

Question 3

What’s a major concern for survivors of PE?

Answer 3

The next PE could kill them. It’s important to treat the source of the emboli.

Question 4

What are etiologies of PE?

Answer 4

Thrombus (blood clot- most common)
Air
Fat
Tacl powder during IVDA
Parasite Eggs
Tumor cells

Question 5

Where do thrombotic etiologies originate?

Answer 5

In the lower extremities as a DVT deep vein thrombosis in calves.

Question 6

What the problem with DCTs in the calves?

Answer 6

20% spread proximally past the knee (popliteal space) increasing the likelihood of embolization.

Question 7

What is virchow’s triad?

Answer 7

Risk factors for PE: Venous stasis, Injury to vessel wall, hypercoagulability

Question 8

What are the signs and symptoms of a DVT?

Answer 8

Swelling, pain, tenderness of extremity, calf pain with forceful dorsiflexion of the ankle.

Question 9

What is Homan’s sign?

Answer 9

Dorsiflexion of the ankle.

Question 10

What diagnostic do you use to find a DVT?

Answer 10

Ultrasound venous doppler.

Question 11

What are symptoms of PE?

Answer 11

Pleural chest pain/back pain
Dyspnea
Tachypnea
Tachycardia
Decreased O2 SAT
Low grade fever
Feelings of anxiety
Evidence of DVT

Question 12

What do you see on an EKG on a pt with PE?

Answer 12

Right heart strain
T wave inversions in the right precordial leads (V1-4) and the inferior leads II, III, aVF
SIQIIITIII Pattern: Deep S wave in lead I, Q wave in lead III, inverted T wave in lead III

Question 13

What are two algorithms we use to guide diagnostics? Which do you start out with?

Answer 13

Well’s Criteria for PE, and PERC.
Well’s.

Question 14

What are the 7 questions for the wells criteria? IN ORDER

Answer 14

3 Clinical signs and symptoms of DVT?
3 PE is #1 diagnosis or likely
1.5 Heart rate > 100
1.5 Immobilization at least 3 days OR surgery in the previous 1.5 4 weeks.
1.5 Previous, objectively diagnosed PE or DVT?
1 Hemoptysis
1 Malignancy w/ treatment within 6 months or palliative?

Question 15

What happens after you added your points for the Well’s criteria?

Answer 15

=< 4 PERC for possible D-dimer
> 4 CT Lung angiogram

Question 16

What are the 8 questions for PERC?

Answer 16

Age =>50
Hr = > 100
SaO2 <95%
Unilateral leg swelling
Hemoptysis
Recent surgery or trauma
Prior PE or DVT
Hormone Use

All worth 1 point

Question 17

What is the score criteria for PERC?

Answer 17

Any positive answer requires D-dimer

Question 18

What is the gold standard for the diagnosis of PE?

Answer 18

Pulmonary angiography- you will see filling defect

Question 19

What is the diagnostic study of choice for PE?

Answer 19

CT Pulmonary agiography

Question 20

What study do you use if your suspect your pt is pregnant or tells you they are allergic to contrast

Answer 20

V/Q scan- but its usually not recommended due to the possible “indeterminant” result

Question 21

Treatment for PE?

Answer 21

Anticoagulate if caused by thrombus
- Can be Admitted or
- If discharged injections of enoxaparin x 3 + oral warfarin immediately
(3 days actually increases coagulability)
IVC Filter

Question 22

What is the prognosis of PE?

Answer 22

Good if the cause is identified and treated appropriately

Question 23

What is an important patient education concept to talk with your pt?

Answer 23

Some patients will require life long anticoagulation