Pulmonary Embolism

Question 1

What is Pulmonary embolism? What conditions (14) is it caused in?

Answer 1

Block of Pulm artery leading to ischemia of lung

In
1. DVT - prolonged, immobile while travelling
2. Surgery - THR (hip), TKR, GIT
3. Prev h/o of pulmonary embolism
4. Pregnancy, postnatal
5. OCP’s, HRT
6. Thrombophilia - Factor 5/prothrombin/protein-c deficiency
7. Malignancy
8. Right heart failure
9. Cardiac arrest
10. Hypotension
11. Obesity
12. Nephrotic syndrome
13. Rheumatic disease
14. Acute Respiratory failure

Question 2

C/F of Pulmonary Embolism

Answer 2

1. SOB - Sudden Onset
2. Pleuritic chest pain
3. Red, painful calf - DVT
4. Tachycardia > tachypnoea
5. Low O2 saturation
6. Hemoptysis
7. Can be assymptomatic/ only SOB

Question 3

Well’s score

Answer 3

Pulmonary embolism
EAT CHIPS
1. Edema/ leg pain (DVT) - 3
2. Alternative diagnosis less likely - 3
3. Tachycardia - 1.5
4. Cancer - 1
5. Hemoptysis - 1
6. Immobilization >3 days -1.5
7. Previous h/o DVT or PE - 1.5
8. Surgery <1month - 1.5

<4 - low risk… D-Dimer increased (sensitive, can be increased in preg etc)
>4 - high risk… CTPA/VQ scan

VQ scan preferred in pregnancy (radiation), renal function decreased and contrast allergy
VQ scan avoided in COPD/pre-existing lung conditions (difficult to read)

Question 4

VQ scan in pulmonary embolism

Answer 4

Ventilation perfusion scan
Done when Well’s score >4
Perfusion abn in PE
VQ scan preferred in pregnancy (radiation) and contrast allergy
VQ scan avoided in COPD/pre-existing lung conditions (difficult to read)

Question 5

Most appropriate, best, initial investigation in Pulmonary embolism with Well’s score > 4?

Answer 5

CTPA (CT-pulmonary angiography)
or
VQ scan (Ventilation perfusion scan)
*NOT XRAY
Well’s < 4 … D-Dimer

Question 6

When do you do ABG in Pulmonary embolism? Preferred before or after CTPA?

Answer 6

Can do before CTPA in
C/o Acute severe SOB and
O2 sat <92%

Question 7

Mx of Pulmonary embolism

Answer 7

Hemodynamically unstable
1. Thrombolytics
2. Pulm embolectomy and interrupt IVC

Hemodynamically Stable
1. NOAC/DOAC i.e., new/direct oral anti-coagulants
Apixaban
Rivaroxaban
Dabigatrin
*for 3 months
2. IVC filter

*Heparin and warfarin not used now, daily monitoring of INR in warfarin difficult

UFH (unfractionated heparin) in PREG

Warfarin used in
1. AF
2. Sev CKD
3. Prosthetic valve

Question 8

If a pregnant patient comes to OPD with signs of DVT, which test do you recommend?
a. CTPA
b. VQ scan
c. Other

Answer 8

c. Other
Deep vein venous doppler to check for clots
Mx for DVT and PE is same
Ideal to avoid stressful investigations like CTPA/VQ scan

Question 9

Most common ECG finding in Pulmonary embolism?

Answer 9

Sinus Tachycardia
NOT S1 Q3 T3

Question 10

D-Dimer in pulmonary embolism

Answer 10

Increased if clot is present
Sensitive
If negative - can exclude pulm embolism
Not specific - increased in pregnancy and other clotting disorders

Question 11

Xray signs in Pulmonary embolism

Answer 11

Xray not required, if done shows
Atelectasis
Wedge-shaped infarction
Pleural-based lesion (Hampton hump)
Oligemia (pulmonary blood volume decrease) of one lobe (Westermark sign)

Question 12

Warfarin for PE used in

Answer 12

1. AF
2. Sev CKD
3. Prosthetic valve