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Year Three - Haematology > Pulmonary Embolism > Flashcards

Pulmonary Embolism Flashcards

1
Q

What is a pulmonary embolism (PE)?

A

It is defined as a condition in which there is formation of a clot within the pulmonary arteries

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2
Q

What is the pathophysiological cause of pulmonary embolisms?

A

The clot formation tends to occur secondary to deep vein thrombosis, in which a thrombus within the deep veins of the lower leg embolises and travels to the right side of the heart and pulmonary arteries

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3
Q

What is the pathophysiological consequence of pulmonary embolisms?

A

The thrombus will block the blood flow to the lung tissue and create strain on the right side of the heart

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4
Q

What twelve risk factors are associated with pulmonary embolisms?

A

Older Age

Family History

Obesity

Pregnancy

Immobility

Hospitalisation

Malignancy

Thrombophilia

Antiphospholipid Syndrome

Polycythaemia

Drug Administration

Central Venous Catheter

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5
Q

Which six drugs are associated with pulmonary embolisms?

A

Combined Oral Contraceptive Pill

Hormone Replacement Therapy

Tamoxifen

Raloxifene

Antipsychotics

Anaesthesia

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6
Q

In order to prevent pulmonary embolism, what advice should individuals on the combined oral contraceptive pill recieve before surgery?

A

They should stop taking the combined oral contraceptive pill 4 weeks before surgery and use alternative contraceptive methods

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7
Q

What are the seven clincial features of pulmonary embolisms?

A

Low Grade Fever

Dyspnoea

Pleuritic Chest Pain

Haemoptysis

Bibasal Lung Crackles

Tachycardia

Tachypnoea

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8
Q

In exams, how does pulmonary embolism tend to present?

A

The patient presents with respiratory clincial features - however the chest examination is normal

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9
Q

What eight investigations are used to diagnose pulmonary embolisms?

A

Pulmonary Embolism Rule-Out Criteria (PERC)

Wells Score

D-Dimer Blood Test

Arterial Blood Gases (ABGs)

ECG Scans

Chest X-Rays (CXRs)

CT Pulmonary Angiogram (CTPA)

Ventilation Perfusion (V/Q) Scans

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10
Q

How is the pulmonary embolism rule-out criteria (PERC) used to investigate pulmonary embolisms?

A

It is used to exclude pulmonary embolism in cases of low clinical suspicion < 15%

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11
Q

What pulmonary embolism rule-out criteria (PERC) result excludes a pulmonary embolism diagnosis?

A

When all of the criteria are absent, reducing the probability to < 2%

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12
Q

What are the seven pulmonary embolism rule-out criteria (PERC)?

A
  • Age > 50 Years Old
  • Heart Rate > 100bpm
  • Previous Pulmonary Embolism/Deep Vein Thrombosis
  • Recent Surgery/Trauma In 4 Weeks
  • Haemoptysis
  • Unilateral Leg Swelling
  • Oestrogen Administration
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13
Q

When is the ‘Wells Score’ used to investigate pulmonary embolisms?

A

It is the first line investigation when the clinical suspicion of pulmonary embolism > 15%

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14
Q

How is the ‘Wells Score’ used to investigate pulmonary embolisms?

A

It is used to predict the risk of pulmonary embolism in suspected cases

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15
Q

What are the seven criteria of the ‘Wells Score’?

A
  • Deep Vein Thrombosis Features = Calf Swelling, Calf Pain With Deep Vein Palpation (3 Points)
  • An Alternative Diagnosis Is At Least As Likely As Pulmonary Embolism (3 Points)
  • Heart Rate > 100bpm (1.5 Points)
  • Immobilisation > 3 Days Or Surgery In Past 4 Weeks (1.5 Points)
  • Previous Deep Vein Thrombosis/Pulmonary Embolism (1.5 Points)
  • Haemoptysis (1 Point)
  • Malignancy = On Treatment, < 6 Months, Palliative (1 Point)
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16
Q

What does a ‘Wells Score’ of > 4 indicate?

A

It indicates that a diagnosis of pulmonary embolism is likely

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17
Q

What should be conducted when a ‘Wells Score’ > 4?

A

Computed tomography pulmonary angiogram (CTPA) should be conducted immediately

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18
Q

What should be conducted when the computed tomography pulmonary angiogram (CTPA) results are positive for pulmonary embolism - Wells Score > 4?

A

No further investigations are required, a diagnosis is obtained

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19
Q

What should be conducted when the computed tomography pulmonary angiogram (CTPA) results are negative for pulmonary embolism - Wells Score > 4?

A

A proximal leg vein ultrasound scan should be conducted if deep vein thrombosis is suspected

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20
Q

What should be conducted when the computed tomography pulmonary angiogram (CTPA) cannot be conducted immediately - Wells Score > 4?

A

An interim therapeutic direct oral anticoagulation (DOAC) should be administered, whilst waiting

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21
Q

What does a ‘Wells Score’ < 4 indicate?

A

It indicates that a diagnosis of pulmonary embolism is unlikely

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22
Q

What should be conducted when a ‘Wells Score’ < 4?

A

D-Dimer blood tests should be conducted

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23
Q

What should be conducted when D-Dimer blood test results are positive - Wells Score < 4?

A

Immediate computed tomography pulmonary angiogram (CTPA) should be conducted

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24
Q

What should be conducted when D-Dimer blood test results are positive and CTPA cannot be conducted immediately - Wells Score < 4?

A

An interim therapeutic direct oral anticoagulation (DOAC) should be administered, whilst waiting

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25
What should be conducted when D-Dimer blood test results are negative - Wells Score < 4?
The anticoagulation should be stopped, and an alternative diagnosis should be considered
26
When are D-Dimer blood tests used to investigate pulmonary embolisms?
They are used to exclude a diagnosis of pulmonary embolism when there is low clinical suspicion However, due to the fact that it can be elevated in other conditions, it cannot provide a definitive diagnosis
27
What D-Dimer blood test result indicates pulmonary embolisms?
> 0.5 ug/mL
28
What arterial blood gas (ABG) result indicates pulmonary embolisms? Explain
Respiratory alkalosis This is due to hyperventilation, resulting in a drop in arterial carbon dioxide partial pressure and thus alkalosis
29
What are the six features of pulmonary embolisms on ECG scans?
Sinus Tachycardia Large S Wave In Lead I Large Q Wave In Lead III Inverted T Wave In Lead III Right Bundle Branch Block Right Axis Deviation
30
What is the most common ECG feature of pulmonary embolisms?
Sinus Tachycardia
31
How do we remember the ECG features of pulmonary embolisms?
S1Q3T3
32
When are chest x-rays (CXRs) used to investigate pulmonary embolisms?
They are used to investigate **all** pulmonary embolism cases, in order to exclude other pathology
33
What is the feature of pulmonary embolisms on chest x-rays?
Wedge shaped opacification
34
What is important to note about the use of chest x-rays when investigating pulmonary embolisms?
In most cases, pulmonary embolisms result in the presentation of a normal chest x-ray scan
35
When are CT pulmonary angiograms used to diagnose pulmonary embolisms?
They are the first line imaging investigation in suspected non-massive pulmonary embolisms
36
What are CT pulmonary angiograms?
A CT scan of the chest, with an intravenous contrast, in order to investigate the pulmonary arteries
37
What is the feature of pulmonary embolisms on CT pulmonary angiograms?
Large saddle embolus within the pulmonary arteries
38
When are ventilation perfusion (V/Q) scans used to diagnose pulmonary embolisms?
They are the first line investigation in those with renal impairment – in which CT pulmonary angiograms are contraindicated They are the second line imaging investigation, used when appropriate facilities exist, chest x-ray results are normal and when there is no significant symptomatic concurrent cardiopulmonary disease
39
What are ventilation perfusion (V/Q) scans?
It involves a nuclear medicine scan which examines air and blood flow in the lungs The first scan measures how well air flows through the lungs – ventilation The second scan measures how well blood flows through the lungs -perfusion The scan images are then compared
40
What is the feature of pulmonary embolisms on ventilation perfusion (V/Q) scans? Explain
Reduced lung perfusion This is due to the thrombus blocking blood flow to the lung tissue
41
What is a contraindication of ventilation perfusion (V/Q) scans?
COPD
42
What is the TCLO blood test result in pulmonary embolisms?
Decreased TCLO Levels
43
What are the three pharmacological management options of pulmonary embolisms?
Direct Oral Anticoagulants (DOACs) Low Molecular Weight Heparin (LMWH) Vitamin K Antagonists (VKAs)
44
When are direct oral anticoagulants (DOACs) used to manage pulmonary embolisms?
They are the first line management option of pulmonary embolism, which should be offered once a diagnosis is suspected and continued when the diagnosis is confirmed
45
What are the two first line direct anticoagulants used to manage pulmonary embolisms?
Apixaban Rivaroxaban
46
What are the two second line direct anticoagulants used to manage pulmonary embolisms? When are they used?
Dabigatran Edoxaban They are administered following low molecular weight heparin administration
47
When is low molecular weight heparin (LMWH) used to manage pulmonary embolisms?
It is the second line management option of pulmonary embolism
48
Name three low molecular weight heparins used to manage pulmonary embolisms
Dalteparin Enoxaparin Tinzaparin
49
Describe the course of low molecular weight heparin used to manage pulmonary embolisms
They should be administered for a 5 – 10 days, followed by direct oral anticoagulants OR vitamin K antagonists for a period of 3 – 6 months
50
When are vitamin K antagonists (VKAs) used to manage pulmonary embolisms?
They are the second line management option of pulmonary embolism – which are administered following low molecular weight heparin administration
51
Name a vitamin K antagonist used to manage pulmonary embolisms
Warfarin
52
What is the pharmacological management option of pulmonary embolisms in active cancer patients?
Direct Oral Anticoagulants (DOACs) - unless contraindicated
53
What are the three pharmacological management options of pulmonary embolisms in severe renal impairment eGFR < 15?
Low Molecular Weight Heparin Unfractioned Heparin Low Molecular Weight Heparin Followed By Vitamin K Antagonist
54
What is the pharmacological management option of pulmonary embolisms in antiphospholipid syndrome patients?
Low Molecular Weight Heparin Followed By Vitamin K Antagonist
55
What are provoked pulmonary embolisms?
It is a pulmonary embolism is due to an obvious precipitating event
56
How long is anticoagulant course treatment in provoked pulmonary embolisms?
3 Months
57
In which circumstance is provoked deep vein thrombosis treated with an anticoagulation treatment course of 6 months?
Active Cancer
58
What are unprovoked pulmonary embolisms?
It is a pulmonary embolism not due to an obvious precipitating event
59
How long is anticoagulant course treatment in unprovoked pulmonary embolisms?
6 Months
60
How do we determine whether pulmonary embolisms can be managed in an outpatient setting?
Pulmonary Embolism Severity Index (PESI) score The key requirements include haemodynamic stability, lack of comorbidities and support at home
61
What are the two surgical management options of pulmonary embolisms?
Thrombolysis Inferior Vena Cava (IVC) Filters
62
When is thrombolysis used to manage pulmonary embolisms?
It is the first line management of pulmonary embolism, in which there is circulatory failure – usually indicated by hypotension
63
What is thrombolysis?
It involves the administration of medications into the circulatory system in order to break up clots and prevent new clots forming
64
Name three thrombolytic drugs used to manage pulmonary embolisms
Streptokinase Altepase Tenecteplase
65
When are inferior vena cava (IVC) filters used to manage pulmonary embolisms?
They are used to manage recurrent pulmonary embolisms, despite adequate pharmacological management
66
What are inferior vena cava (IVC) filters?
It involves insertion of a device into the inferior vena cava to stop clots formed in the deep veins of the leg from moving to the pulmonary arteries
67
What is a high risk factor of pulmonary embolisms in pregnant patient?
Previous history of pulmonary embolism
68
What prophylactic management should be administered in pregnant patients with high risk factors for pulmonary embolism?
Low molecular weight heparin should be administered throughout the antenatal period, alongside expert input
69
What are the four intermediate risk factors of pulmonary embolism in pregnant patients?
* Recent Hospitalisation * Recent Surgery * Co-Morbidities * High Risk Thrombophilia
70
What prophylactic management should be administered in pregnant patients with intermediate risk factors for pulmonary embolism?
Low molecular weight heparin should be considered throughout the antenatal period, alongside expert input
71
What are the eleven low risk factors of pulmonary embolism in pregnant patients?
* Age > 35 Years Old * Pulmonary Embolism Family History * Parity > 3 * Multiple Pregnancy * In Vitro Fertilisation Pregnancy * Immobility * Low Risk Thrombophilia * Gross Varicose Veins * Pre-Eclampsia * Body Mass Index > 30 * Smoker
72
What prophylactic management should be administered when individuals have three low risk factors of pulmonary embolism?
Low molecular weight heparin should be administered from 28 weeks’ gestation and continued until 6 weeks postnatal
73
What prophylactic management should be administered when individuals have more than four low risk factors of pulmonary embolism?
Immediate management with low molecular weight heparin should be administered until 6 weeks postnatal
74
Which two pharmacological management options of pulmonary embolisms are contraindicated in pregnancy?
Direct Oral Anticoagulants Warfarin
75
When is prophylactic management of pulmonary embolism administered in hospitalised patients?
When the pulmonary embolism risk is deemed greater than the bleeding risk – determined on an individual case basis
76
What is the prophylactic management option of pulmonary embolisms in medical hospitalised patients?
Pharmacological anticoagulation, such as fondaparinux, low molecular weight heparin or unfractioned heparin should be administered
77
What is the prophylactic management option of pulmonary embolisms in surgical hospitalised patients?
The anti-embolism stockings are the first line management option However, when deemed at high risk pharmacological management should be additionally administered The post-surgical pharmacological prophylaxis administered is dependent upon the surgical procedure

Year Three - Haematology (5 decks)

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