Pulmonary Embolism Flashcards
What are the risk factors for a DVT?
THROBUS
T: Trauma or thrombophilia,
H: Hormonal (COCP, pregnancy, HRT)
R: Relatives (family history) and Recent surgery
O: Old age and Obesity
M: Malignancy,
B: bone fractures
O: Obesity
S: Smoking,
I: Immobilisation
S: Sickness
What are the signs and symptoms of a DVT?
Unilateral warm, swollen calf or thigh. Measure calf circumference 3x difference increases probability of DVT.
Pain on palpation of deep veins
Distention of superficial veins
Pitting oedema
What is the scoring system for suspected DVT?
2 Level WELLS score - DVT is likely if score is 2+
and unlikely if score is 1 or less
What are the investigations if 2 level wells score >2?
Proximal leg ultrasound within 4 hours. If positive then start treatment. If negative then do D-dimer.
If scan is negative but D-dimer is positive then stop anticoagulation and repeat scan in one week.
If cannot get ultrasound in 4h then do D-dimer, if positive then start anticoagulation and await scan.
What are the investigations if 2 level wells score is 1 or less?
Perform D-dimer within 4 hours. If positive then do ultrasound scan within 4 hours. If negative then DVT is unlikely so consider alternative diagnosis
What is the treatment for DVT?
1st line = DOAC (apixavan or rivaroxiban) even if patient has cancer.
In severe renal impairment (eGFR < 15) then LMWH.
3 months for provoked DVT
6 months for unprovoked DVT
What are the features of a pulmonary embolism?
Pleuritic chest pain,
Dyspnoea,
Haemoptysis,
Tachycardia,
Tachypnoea,
Crackles and fever are also common
Severity of a PE is determined why what?
- The PE severity index (PESI) score
- Signs of right heart strain
- Cardiovascular shock
- Troponin or NT-proBNP
What are the initial investigations for a PE?
- ECG (most commonly sinus tachycardia) - exclude MI or pericarditits
- Bloods: D-dimer, FBC, CRP, U&Es, clotting
- ABG
- 2-level Wells score
- Chest x ray to exclude other pathology. May see wedge-shaped opacification in PE.
- Anticoagulation without delay then determine if haemodynamically instable. This is if a patients systolic is less an 90mmHg or has dropped by 40+mmHg for more than 15mins in absence of another cause or if patient has undergone cardiac arrest
What are the investigations for PE if WELLS score > 4?
Immediate CTPA. If CTPA is negative then consider proximal leg vein ultrasound if DVT suspected
What are the investigations for PE if WELLS score < 4?
Do D-dimer test.
If positive - Do immediate CTPA. If any delay then give interim anticoagulation
If negative - stop anticoagulation and consider alternative diagnosis
What is the management of an acute PE if patient is haemodynamically stable?
Determine whether patient is low or intermediate risk. Patient is intermediate risk if they have one of the following:
- Clinical signs of a severe PE/serious co-morbidity (high PESI)
- Right ventricular dysfunction on ECHO/CT
What determines whether a patient is intermediate low risk or intermediate high risk and the management of each?
Whether they are troponin positive or not
Intermediate low risk patients - hospitalised.
Intermediate high risk patients - Hospitalised and monitored, consider reperfusion therapy if deteriorate
What is the management of low risk patients with an acute PE?
Early discharge with home treatment
What are the treatments for right ventricular failure in acute high risk pulmonary embolisms?
Fluid resuscitation: 500ml bolus over 15-30mils however may cause volume overload and worsen RV strain.
Vasopressors and inotropes.
Veno-arterial ECMO (complications with long term use) - extracorporeal membrane oxygenation
