Pulmonary Embolism Flashcards
PE
What is it?
When a VTE gets stuck in the pulmonary arterial vasculature
venousthromboembolus
PE
Most emboli arise from ____ .
lower extremity proximal veins (iliac, femoral, and popliteal)
PE
Symptoms:
5
The diagnosis is often difficult to make based on signs and symptoms alone. In these situations, the presence or absence of risk factors for DVT can help inform investigation and management.
- Acute breathlessness
- Pleuritic chest pain
- Haemoptysis
- Dizziness
- Syncope
PE
Signs:
9
The diagnosis is often difficult to make based on signs and symptoms alone. In these situations, the presence or absence of risk factors for DVT can help inform investigation and management.
- Pyrexia
- Cyanosis
- Tachypnoea
- Tachycardia
- Hypotension
- Raised JVP
- Pleural rub
- Pleural effusion
- Concurrently swollen lower limb
PE
The diagnosis is often difficult to make based on signs and symptoms alone. In these situations, the presence or absence of risk factors for DVT can help inform investigation and management.
Risk factors for DVT:
7
- Recent surgery
- Thrombophilia
- Leg fracture
- Immobility
- Malignancy
- Pregnancy/postpartum; Pill/HRT
- Previous PE
PE
What scoring system is used to help clinicians establish the likelihood of PE in a pt?
Well’s criteria
PE
How do we interpret the Well’s criteria score?
How does it influence our management?
<4 PE unlikely (D-dimer to rule out)
>4 PE likely (diagnostic imaging)
PE
What is the recommended first-line imaging modality?
CTPA
it is sensitive and specific in confirming a diagnosis of PE
CT pulmonary angiography
PE
If a CTPA if not available? What can be used to aid diagnosis?
ventilation-perfusion (V/Q) scan
PE
Serum D-dimers have a ____ sensitivity but ____ specificity for PE.
Why?
high sensitivity
low specificity
because they are increased if there is any thrombosis, inflammation, infection or malignancy, or if the patient is post-op
PE
When should a serum d-dimer be performed?
Well’s score <4
A negative D-dimer test effectively excludes a PE in those with a low or intermediate clinical probability, and imaging is NOT required. In those with high probability (Wells >4), a CTPA should be obtained regardless of d-dimer result.
PE
Apart from CTPA, V/Q scan and D-dimer, what other test can be done?
- ECG
- Chest X-ray
- ABG
PE
What is a Hemodynamically unstable PE?
a PE that results in hypotension
PE
How is hypotension defined?
a systolic blood pressure <90 mmHg or a drop in systolic blood pressure of ≥40 mmHg from baseline for a period
>15 minutes
PE
Why is haemodynamically unstable PE a medical emergency?
It requires urgent attention as death from hemodynamically unstable PE often occurs within the first two hours, and the risk remains elevated for up to 72 hours after presentation.
PE
How do we manage haemodynamically unstable PE?
- immediate thrombolysis
- establishment of IV access
- resuscitation
- commencement of heparin
If systolic BP <90mmHg
- rapid colloid infusion
- request ICU input for further intervention
PE
1st line management of a PE:
- respiratory support (supplemental O2)
target SpO₂ of 94-98% (88-92% in COPD) - fluids (hypotension)
pts at imminent risk of death + low risk of bleeding :
- systemic thrombolytic therapy
(followed by anticoag)
PE
What are the best thrombolytic agents for thrombolysis in PE?
- Recombinant tPA
- streptokinase
- recombinant human urokinase
PE
Absolute contraindications to systemic thrombolytic therapy in acute PE include:
- Intracranial neoplasm
- Recent intracranial or spinal trauma or surgery
- History of a haemorrhagic stroke
- Active bleeding (risk of)
- Non-haemorrhagic stroke (<3 months prior)
PE
Relative contraindications to systemic thrombolytic therapy in acute PE include:
- Severe uncontrolled hypertension
- Non-haemorrhagic stroke >3 months prior
- Surgery within the previous 10 days
- Pregnancy
PE
For patients who do not have massive PEs, or are not haemodynamically unstable, ____ are now the first line treatment for confirmed or suspected VTE, including in most cancer patients.
DOACs
PE
When is embolectomy considered?
- pts with hemodynamically unstable PE in whom thrombolytic therapy is contraindicated
- pts where thrombolysis has failed
PE
In an embolectomy, emboli can be removed ____ or using a ____.
surgically
catheter
PE
What is an Inferior vena cava (IVC) filter?
a small device that can stop blood clots from going up into the lungs
