Pulmonary Embolism

Question 1

First line of investigation of Pulmonary Embolism?

Answer 1

CTPA- Computer tomographic pulmonary angiography

Question 2

Features of pulmonary embolism?

Answer 2

*Tachypnea- (high resp rate over 20)
abnormal rapid breathing

*Crackles

*Tachycardia- heart rate over 100

*Fever (temperature over 37.8)

Question 3

Wells Score interpretation

Answer 3

> 4 - CTPA
<4- D dimer

Question 4

Acute shortness of breath, pleuritic chest pain, and haemoptysis suggest

Answer 4

Pulmonary Embolism

Question 5

Investigating suspected PE: if the CTPA is negative then consider…..

Answer 5

a proximal leg vein ultrasound scan if DVT is suspected

Question 6

Tachypnea (respiratory rate >20/min) - 96%

Crackles - 58%

Tachycardia (heart rate >100/min) - 44%

Fever (temperature >37.8°C) - 43%

Looking at the commonality %, what does this indicate

Answer 6

Pulmonary Embolism

Question 7

Suspected PE ptx….

The doctor would like to complete an investigation but there is a prolonged wait for a computed tomography pulmonary angiogram (CTPA).

What is the next best step in management for this patient?

Answer 7

Prescribe Rivaroxiban

Strong suspicion of PE but a delay in the scan: start on treatment dose anticoagulant meanwhile

Question 8

How much of the PERC ( Pulmonary Embolism Rule Out Criteria) must be absent before clearing PE from suspicion?

Answer 8

all the criteria must be absent to have negative PERC result, i.e. rule-out PE

Question 9

PERC ( Pulmonary Embolism Rule Out Criteria) what does it consists off?

Answer 9

Age
Heart Rate
Oxygen Sat
DVT or PE previously
Recent surgery or trauma
Haemotypisis
Unilateral leg swelling
Oestrogen Use ( remember COCP, HRT)

Question 10

Wells Score Consideration and Score Calculation

Answer 10

Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) 3

An alternative diagnosis is less likely than PE 3

Heart rate > 100 beats per minute 1.5

Immobilisation for more than 3 days or surgery in the previous 4 weeks 1.5

Previous DVT/PE 1.5

Haemoptysis 1

Malignancy (on treatment, treated in the last 6 months, or palliative) 1

Question 11

‘Unprovoked’ pulmonary embolisms are typically treated for…..

Answer 11

for 6 months

Question 12

First line of management to be given to Ptx with suspected PE

Answer 12

apixaban or rivaroxaban (both DOACs) should be offered first-line following the diagnosis of a PE

Question 13

if neither apixaban or rivaroxaban are suitable to give for 1st line management of PE, what do you offer

Answer 13

LMWH followed by dabigatran or edoxaban

OR LMWH followed by a vitamin K antagonist (VKA, i.e. warfarin)

Question 14

If the ptx has cancer, what do you offer to give for 1st line management of PE

Answer 14

DOAC

Question 15

if renal impairment is severe (e.g. < 15/min) , what do you offer Ptx with first line management of PE

Answer 15

LMWH, unfractionated heparin or

LMWH followed by a VKA (Warfarin)

Question 16

if the patient has antiphospholipid syndrome (specifically ‘triple positive’ in the guidance), what do you offer Ptx with first line management of PE

Answer 16

LMWH followed by a VKA should be used

Question 17

How long should anticoags should be given in PE

Answer 17

all patients should have anticoagulation for at least 3 months

Question 18

Provoked PE how long do you give it for?

Answer 18

if the VTE was provoked the treatment is typically stopped after the initial 3 months (3 to 6 months for people with active cancer)

Question 19

First-line treatment for massive PE where there is circulatory failure (e.g. hypotension)

Answer 19

THROMBOLYSIS is now recommended as the first-line treatment for massive PE where there is circulatory failure (e.g. hypotension).

“alteplase”

Question 20

What is Provoked VTE

Answer 20

a provoked VTE is due to an obvious precipitating event e.g. immobilisation following major surgery. The implication is that this event was transient and the patient is no longer at increased risk

Question 21

What is unprovoked VTE?

Answer 21

an unprovoked VTE occurs in the absence of an obvious precipitating event, i.e. there is a possibility that there are unknown factors (e.g. mild thrombophilia) making the patient more at risk from further clots

Question 22

The most common ECG change in PE is

Answer 22

sinus tachycardia

Question 23

Massive PE + hypotension - what do you give ?

‘PTX IS HAEMODYNAMICALLY INSTABLE’

Answer 23

thrombolyse such as Alteplase

individual displays signs of a pulmonary embolism (PE) on echocardiography and presents with haemodynamic instability (blood pressure < 90/60mmHg), necessitating immediate thrombolysis.

Alteplase, a thrombolytic agent, is indicated to dissolve clots in cases of massive PE accompanied by haemodynamic compromise.

Question 24

PE is suspected and

‘PTX IS HAEMODYNAMICALLY STABLE’ - what do you give?

Answer 24

Apixaban