Pulmonary Embolism Flashcards
What is a Pulmonary Embolism?
A condition where a blood clot (thrombus) forms in the pulmonary arteries.
How is a pulmonary embolism usually caused?
A deep vein thrombosis (DVT) develops in the legs and travels (embolised) through the venous system and the right side of the heart to the pulmonary arteries in the lungs.
What are the consequences of the pulmonary arteries bceoming blocked?
The blood flow to the lung tissue is blocked and this creates strain on the right side of the heart.
What are potential risk factors for the development of a pulmonary embolism?
- Immobility
- Recent surgery
- Long haul flights
- Pregnancy
- Hormone therapy with oestrogen
- Malignancy
- Thrombophilia
How does a pulmonary embolism usually present?
chest pain- pleuritic
dyspnoea
haemoptysis
tachycardia
tachypnoea
Haemodynamic instability causing hypotension
What additional signs can present with a PE?
Signs of a DVT (unilateral leg swelling and tenderness)
What is the initial investigation for someone presenting with a potential PE?
Preform a WELL’s score
What is the next step if the WELL’s score indicates that a PE is likely?
CTPA
What is the next step if the WELL’s score indicates that a PE is unlikely?
Arrange a D-dimer
If that is positive then carry out a CTPA
What is the first line management of a pulmonary embolism?
DOAC’s
What are examples of DOAC’s
Apixaban
Rivaroxaban
How long are patients with a PE given DOAC’s if it is an provoked VTE?
3 months
What is an alternative to DOAC’s for people with PE’s?
LMWH
enoxaparin or dalteparin
What is the management of a massive PE where there is circulatory failure (e.g. hypotension)?
Thrombolysis
What is the management of a patient with a PE and renal impairment (< 15/min)?
LMWH, unfractionated heparin or LMWH followed by a VKA
What is the manage of a patient with a PE and antiphospholipid syndrome?
LMWH followed by a VKA
How long are patients with a PE given DOAC’s if it is an unprovoked VTE?
A further 3 months (6 months total)
What might be considered for a patient with repeat pulmonary embolisms despite adequate anticoagulation?
Inferior vena cava (IVC) filters
Why would a patient be allocated 3 points on the WELL’s score?
Clinical signs and symptoms of a deep vein thrombosis (DVT)
If no alternative diagnosis is more likely than a PE
Why would a patient be allocated 1.5 points on the WELL’s score?
Tachycardia
Patient has been immobile for more than 3 days or had major surgery within the last month
If the patient has had a previous PE or DVT
Why would a patient be allocated 1 points on the WELL’s score?
Patient has haemoptysis
If there is an active malignancy
What is the next step if the patients WELL’s score is less than 4?
Measure D-dimer
Why should a D-dimer only be used if the clinical suspicion of a PE is low?
It has a high negative predictive value but a low specificity
What does a low d-dimer exclude?
A PE
What is a high d-dimer an indication for?
Diagnostic imaging (by CTPA or V/Q scan).
What is the next step if the WELL’s score is more than 4?
Diagnostic imaging (by CTPA or V/Q scan).
What is usually given
What is the classic triad of symptoms of a PE?
SOB
Haemoptysis
Pleuritic chest pain
What are the main signs of a pulmonary embolism?
Tachycardia
Tachypnoea
Hypoxia
What can be the only presenting sign of a PE?
Tachycardia
What should all patients in hospital at risk of a VTE be given?
prophylaxis with a low molecular weight heparin such as enoxaparin
What other investigations can be carried out for a PE?
ECG
Chest x-ray
What might you find on a chest x-ray of someone with a PE?
Usually normal
Sometimes see a wedge-shaped opacification
What ECG change is associated with a PE but rarely seen?
S1Q3T3
What is S1Q3T3?
Large S wave in lead I
Large Q wave in lead III
Inverted T wave in lead III
What are other ECG chnages are associated with a PE?
Sinus tachycardia- MAIN
right bundle branch block and right axis deviation- if
When might a V/Q scan be done rather than a CTPA?
Renal impairment
Contrast allergy
At risk from radiation
How long should patients be given anticoagulation if there is an ongoing cause (e.g. a thrombophilia)?
Life long
