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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
Q

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

A

The anticoagulation should be stopped, and an alternative diagnosis should be considered

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26
Q

When are D-Dimer blood tests used to investigate pulmonary embolisms?

A

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

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27
Q

What D-Dimer blood test result indicates pulmonary embolisms?

A

> 0.5 ug/mL

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28
Q

What arterial blood gas (ABG) result indicates pulmonary embolisms? Explain

A

Respiratory alkalosis

This is due to hyperventilation, resulting in a drop in arterial carbon dioxide partial pressure and thus alkalosis

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29
Q

What are the six features of pulmonary embolisms on ECG scans?

A

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

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30
Q

What is the most common ECG feature of pulmonary embolisms?

A

Sinus Tachycardia

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31
Q

How do we remember the ECG features of pulmonary embolisms?

A

S1Q3T3

32
Q

When are chest x-rays (CXRs) used to investigate pulmonary embolisms?

A

They are used to investigate all pulmonary embolism cases, in order to exclude other pathology

33
Q

What is the feature of pulmonary embolisms on chest x-rays?

A

Wedge shaped opacification

34
Q

What is important to note about the use of chest x-rays when investigating pulmonary embolisms?

A

In most cases, pulmonary embolisms result in the presentation of a normal chest x-ray scan

35
Q

When are CT pulmonary angiograms used to diagnose pulmonary embolisms?

A

They are the first line imaging investigation in suspected non-massive pulmonary embolisms

36
Q

What are CT pulmonary angiograms?

A

A CT scan of the chest, with an intravenous contrast, in order to investigate the pulmonary arteries

37
Q

What is the feature of pulmonary embolisms on CT pulmonary angiograms?

A

Large saddle embolus within the pulmonary arteries

38
Q

When are ventilation perfusion (V/Q) scans used to diagnose pulmonary embolisms?

A

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
Q

What are ventilation perfusion (V/Q) scans?

A

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
Q

What is the feature of pulmonary embolisms on ventilation perfusion (V/Q) scans? Explain

A

Reduced lung perfusion

This is due to the thrombus blocking blood flow to the lung tissue

41
Q

What is a contraindication of ventilation perfusion (V/Q) scans?

A

COPD

42
Q

What is the TCLO blood test result in pulmonary embolisms?

A

Decreased TCLO Levels

43
Q

What are the three pharmacological management options of pulmonary embolisms?

A

Direct Oral Anticoagulants (DOACs)

Low Molecular Weight Heparin (LMWH)

Vitamin K Antagonists (VKAs)

44
Q

When are direct oral anticoagulants (DOACs) used to manage pulmonary embolisms?

A

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
Q

What are the two first line direct anticoagulants used to manage pulmonary embolisms?

A

Apixaban

Rivaroxaban

46
Q

What are the two second line direct anticoagulants used to manage pulmonary embolisms? When are they used?

A

Dabigatran

Edoxaban

They are administered following low molecular weight heparin administration

47
Q

When is low molecular weight heparin (LMWH) used to manage pulmonary embolisms?

A

It is the second line management option of pulmonary embolism

48
Q

Name three low molecular weight heparins used to manage pulmonary embolisms

A

Dalteparin

Enoxaparin

Tinzaparin

49
Q

Describe the course of low molecular weight heparin used to manage pulmonary embolisms

A

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
Q

When are vitamin K antagonists (VKAs) used to manage pulmonary embolisms?

A

They are the second line management option of pulmonary embolism – which are administered following low molecular weight heparin administration

51
Q

Name a vitamin K antagonist used to manage pulmonary embolisms

A

Warfarin

52
Q

What is the pharmacological management option of pulmonary embolisms in active cancer patients?

A

Direct Oral Anticoagulants (DOACs) - unless contraindicated

53
Q

What are the three pharmacological management options of pulmonary embolisms in severe renal impairment eGFR < 15?

A

Low Molecular Weight Heparin

Unfractioned Heparin

Low Molecular Weight Heparin Followed By Vitamin K Antagonist

54
Q

What is the pharmacological management option of pulmonary embolisms in antiphospholipid syndrome patients?

A

Low Molecular Weight Heparin Followed By Vitamin K Antagonist

55
Q

What are provoked pulmonary embolisms?

A

It is a pulmonary embolism is due to an obvious precipitating event

56
Q

How long is anticoagulant course treatment in provoked pulmonary embolisms?

A

3 Months

57
Q

In which circumstance is provoked deep vein thrombosis treated with an anticoagulation treatment course of 6 months?

A

Active Cancer

58
Q

What are unprovoked pulmonary embolisms?

A

It is a pulmonary embolism not due to an obvious precipitating event

59
Q

How long is anticoagulant course treatment in unprovoked pulmonary embolisms?

A

6 Months

60
Q

How do we determine whether pulmonary embolisms can be managed in an outpatient setting?

A

Pulmonary Embolism Severity Index (PESI) score

The key requirements include haemodynamic stability, lack of comorbidities and support at home

61
Q

What are the two surgical management options of pulmonary embolisms?

A

Thrombolysis

Inferior Vena Cava (IVC) Filters

62
Q

When is thrombolysis used to manage pulmonary embolisms?

A

It is the first line management of pulmonary embolism, in which there is circulatory failure – usually indicated by hypotension

63
Q

What is thrombolysis?

A

It involves the administration of medications into the circulatory system in order to break up clots and prevent new clots forming

64
Q

Name three thrombolytic drugs used to manage pulmonary embolisms

A

Streptokinase

Altepase

Tenecteplase

65
Q

When are inferior vena cava (IVC) filters used to manage pulmonary embolisms?

A

They are used to manage recurrent pulmonary embolisms, despite adequate pharmacological management

66
Q

What are inferior vena cava (IVC) filters?

A

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
Q

What is a high risk factor of pulmonary embolisms in pregnant patient?

A

Previous history of pulmonary embolism

68
Q

What prophylactic management should be administered in pregnant patients with high risk factors for pulmonary embolism?

A

Low molecular weight heparin should be administered throughout the antenatal period, alongside expert input

69
Q

What are the four intermediate risk factors of pulmonary embolism in pregnant patients?

A
  • Recent Hospitalisation
  • Recent Surgery
  • Co-Morbidities
  • High Risk Thrombophilia
70
Q

What prophylactic management should be administered in pregnant patients with intermediate risk factors for pulmonary embolism?

A

Low molecular weight heparin should be considered throughout the antenatal period, alongside expert input

71
Q

What are the eleven low risk factors of pulmonary embolism in pregnant patients?

A
  • 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
Q

What prophylactic management should be administered when individuals have three low risk factors of pulmonary embolism?

A

Low molecular weight heparin should be administered from 28 weeks’ gestation and continued until 6 weeks postnatal

73
Q

What prophylactic management should be administered when individuals have more than four low risk factors of pulmonary embolism?

A

Immediate management with low molecular weight heparin should be administered until 6 weeks postnatal

74
Q

Which two pharmacological management options of pulmonary embolisms are contraindicated in pregnancy?

A

Direct Oral Anticoagulants

Warfarin

75
Q

When is prophylactic management of pulmonary embolism administered in hospitalised patients?

A

When the pulmonary embolism risk is deemed greater than the bleeding risk – determined on an individual case basis

76
Q

What is the prophylactic management option of pulmonary embolisms in medical hospitalised patients?

A

Pharmacological anticoagulation, such as fondaparinux, low molecular weight heparin or unfractioned heparin should be administered

77
Q

What is the prophylactic management option of pulmonary embolisms in surgical hospitalised patients?

A

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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