Pulmonary Embolism

Question 1

List 10 risk factors for PE (5 major and 3minor)

Answer 1

Major – SLOMMP

Surgery – major abdominal/pelvic, hip/knee replacements, post ICU
Lower limb problems – #, varicose veins
Obstetrics – late pregnancy, C/S, puerperium
Malignancy – abdominal/pelvic, advanced/metastatic
Mobility – hospitalization, institutional care
Previous VTE
Minor – COM

Cardiovascular – congenital heart disease, CHF, HT, superficial venous thrombosis, CVL
Oestrogens – OCP, HRT
Miscellaneous – COPD, neurological disability, occult malignancy, thrombotic disorder, long distance travel, obesity, other (IBD, nephrotic syndrome, dialysis, myeloproliferative disorders, paroxysmal nocturnal haemoglobinuria, Bechet’s disease)

Thrombophillias

Question 2

What are the markers of myocardial injury in acute PE (2)

Answer 2

Trop T or 1 positive

Question 3

What what are the markers of RV dysfunction in acute PE (3)

Answer 3

RV dilatation, hypokinesis or pressure load on echocardiography
RV dilation on spiral CT
BNP or NT-proBNP elevation

Question 4

What are the clinical markers in acute PE (2)

Answer 4

Shock
Hypotension

Question 5

What are the ECG changes seen in PE

Answer 5

Sinus tachy
SlQlllTlll- Deep S wave in lead I, Q wave in III, inverted T wave in III.
Non-specific ST changes or T wave changes-Including ST elevation and depression
Right axis deviation
RV strain pattern
p pulmonale-RA enlargement, peaked p in lead ll
ARBBB
Atrial tacky arrhythmias -AFib
Dominant R wave in V1-acute RV dilatation

Question 6

What is the gold standard diagnostic test for PE

Answer 6

CT pulmonary angiogram

Question 7

What are the advantages of CTPA(CT Pulmonary angiogram) (3)

Answer 7

It is fast
Accurate and specific
Can diagnose other intrathoracic pathology

Question 8

What are the disadvantages of CTPA (CT pulmonary angiogram) in diagnosing PE

Answer 8

Pt movement can cause 5-10% CTs unreadable
Requires contrast, which is subject to the contraindications applicable to its usage
Radiation exposure

Question 9

List the imaging investigations in PE

Answer 9

CXR
CTPA
Echo
USS
V/Q-only when CT is contraindicated (breast cancer ?)

Question 10

What are the absolute contraindications of thrombolysis in PE (5)

Answer 10

bleeding
recent stroke
HI
current GI bleeding relative PUD
surgery within 7 day
prolonged CPR

Question 11

What is the desirable INR in normal individuals

Answer 11

2-3

Question 12

Outline the wells probability score

Answer 12

Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins)
3.0
An alternate diagnosis is less likely than PE
3.0
Heart rate is >100 bpm
1.5
Immobilisation at least 3 days, or surgery in previous 4 weeks
1.5
Previous PE/DVT
1.5
Haemoptysis
1.0
Malignancy