Pulmonary Embolism Flashcards
First line of investigation of Pulmonary Embolism?
CTPA- Computer tomographic pulmonary angiography
Features of pulmonary embolism?
*Tachypnea- (high resp rate over 20)
abnormal rapid breathing
*Crackles
*Tachycardia- heart rate over 100
*Fever (temperature over 37.8)
Wells Score interpretation
> 4 - CTPA
<4- D dimer
Acute shortness of breath, pleuritic chest pain, and haemoptysis suggest
Pulmonary Embolism
Investigating suspected PE: if the CTPA is negative then consider…..
a proximal leg vein ultrasound scan if DVT is suspected
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
Pulmonary Embolism
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?
Prescribe Rivaroxiban
Strong suspicion of PE but a delay in the scan: start on treatment dose anticoagulant meanwhile
How much of the PERC ( Pulmonary Embolism Rule Out Criteria) must be absent before clearing PE from suspicion?
all the criteria must be absent to have negative PERC result, i.e. rule-out PE
PERC ( Pulmonary Embolism Rule Out Criteria) what does it consists off?
Age
Heart Rate
Oxygen Sat
DVT or PE previously
Recent surgery or trauma
Haemotypisis
Unilateral leg swelling
Oestrogen Use ( remember COCP, HRT)
Wells Score Consideration and Score Calculation
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
‘Unprovoked’ pulmonary embolisms are typically treated for…..
for 6 months
First line of management to be given to Ptx with suspected PE
apixaban or rivaroxaban (both DOACs) should be offered first-line following the diagnosis of a PE
if neither apixaban or rivaroxaban are suitable to give for 1st line management of PE, what do you offer
LMWH followed by dabigatran or edoxaban
OR LMWH followed by a vitamin K antagonist (VKA, i.e. warfarin)
If the ptx has cancer, what do you offer to give for 1st line management of PE
DOAC
if renal impairment is severe (e.g. < 15/min) , what do you offer Ptx with first line management of PE
LMWH, unfractionated heparin or
LMWH followed by a VKA (Warfarin)
if the patient has antiphospholipid syndrome (specifically ‘triple positive’ in the guidance), what do you offer Ptx with first line management of PE
LMWH followed by a VKA should be used
How long should anticoags should be given in PE
all patients should have anticoagulation for at least 3 months
Provoked PE how long do you give it for?
if the VTE was provoked the treatment is typically stopped after the initial 3 months (3 to 6 months for people with active cancer)
First-line treatment for massive PE where there is circulatory failure (e.g. hypotension)
THROMBOLYSIS is now recommended as the first-line treatment for massive PE where there is circulatory failure (e.g. hypotension).
“alteplase”
What is Provoked VTE
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
What is unprovoked VTE?
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
The most common ECG change in PE is
sinus tachycardia
Massive PE + hypotension - what do you give ?
‘PTX IS HAEMODYNAMICALLY INSTABLE’
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.
PE is suspected and
‘PTX IS HAEMODYNAMICALLY STABLE’ - what do you give?
Apixaban
