Pulmonary Embolism

Question 1

What is a pulmonary embolism?

Answer 1

A blood clot in the lungs/ pulmonary blood vessels. A part of a DVT breaks off and travels to the lungs, making it hard for the patient to breathe.

Question 2

What are the clinical typical signs of a pulmonary embolism to look out for?

Answer 2

Swelling or pain or redness in a leg - from DVT
Pain that worses with activity - from DVT
Fatigue in a certain leg - from DVT
Pleuritic chest pain - from blockage in the vessel causes ischaemia, inflammation and infarction
Haemoptysis - bleeding into the alveoli due to infarction
Sudden onset of shortness of breath - inability to breathe due to the blockage of the vessel
Hypoxia
Tachycardia
Low grade pyrexia
Hypotension
Signs of right heart strain - raised JVP, parasternal heave, loud p2

Question 3

What are some differential diagnosis of PE?

Answer 3

Asthma/COPD exacerbation
Pneumothorax
Pneumonia
Myocardial infarction
Acute heart failure

Question 4

What is the wells score and how is it used?

Answer 4

When PE is suspected, then the wells score is completed to stratify the risk of the patient. To inform the patients management ie order D dimer vs CTPA etc

Question 5

What are some pulmonary embolism specific signs to know?

Answer 5

ECG - normal or sinus tachycardia
ABG - normal or type 1 respiratory failure (hypoxemia)
ECG - S1Q3T3 in less than 20% of patient. deep S wave in lead 1, pathologic Q waves in lead 3, inverted T wave in lead 3

Question 6

How to manage a patient with pulmonary embolism?

Answer 6

• order bloods. crp for inflammation, u+e for renal function before ctpa, lft to see suitability for anticoag, troponin for myocardial damage, coagulation screen for anticoag, screen for thrombophilia
• order CXR to rule of differentials. order CTPA to diagnose PE if patient can tolerate. V/Q for patient with renal impairment. Order transthoracic echocardiogram for patient showing signs of right heart strain.
• treat all ABCDE signs like normal including pain and extra symptoms
• LMWH or DOAC administered if PE even if not confirmed. after confirmed, continue DOAC. duration of anticoagulation depends on aetiology.
• if patient has massive PE (aka HYPOTENSION = obstructive shock for over 15 mins) thrombolysis should be administered via IV bolus of altepase. if thombolysis is contraindicated the embolectomy.
• if patient has recurrent DVT consider IVC filter.

Question 7

What medications should you prescribe for pulmonary embolism initially?

Answer 7

DOAC - apixaban or rivaroxaban
2x a day
they inhibit factor Xa, preventing generation of thrombin and reducing clots;

Question 8

What are risk factors for PE?

Answer 8

history of surgery
pregnancy
taking oral contraceptive
history of cancer
reoccuring dvt

Question 9

In a massive PE, when is thrombolysis contraindicated?

Answer 9

being over 75
high risk for haemorrhage - ie active bleeding
presence of brain tumour
uncontrolled hypertension
recent major surgery or trauma
recent stroke with 3 months
pregnancy
aortic dissection
bleeding disorders

Question 10

How does pulmonary embolism severity index impact how a patient will be managed?

Answer 10

Class 1/2 - low risk. can be managed as an outpatient if haemodynamically stable with no comorbidities

class 3+ - admit patient for close monitoring.

Question 11

How does a provked vs unprovoked pulmonary embolism affect treatment?

Answer 11

Provoked - risk factors for the pulmonary embolism
in this case, treatment with DOAC for 3 months is appropriate

unprovoked - no risk factors present for the pulmonary emoblism
in this case, treatment with DOAC for 6 months is appropriate