Pulmonary Embolism Flashcards
T/F: DVT can be located only in the lower extremities
F: It can be in either upper or lower extremities
It is a condition characterized by the presence of a clot in the deep venous sytem
Deep Vein Thrombosis (DVT)
What is the pathway of the clot causing pulmonary embolism?
Vena cava -> right atrium -> right ventricle -> pulmonary artery -> clot lodges at PA -> pulmonary embolism
This medical condition occurring after DVT/PE is characterized by symptoms of breathlessness, especially with exertion
a. Post-PE Syndrome
b. Chronic Thromboembolic pulmonary Hypertension (CTEPH)
c. Post-thrombotic syndrome
b. Chronic Thromboembolic pulmonary Hypertension (CTEPH)
This medical condition occurring after DVT/PE could present with right ventricular dysfunction after PE diagnosis
a. Post-PE Syndrome
b. Chronic Thromboembolic pulmonary Hypertension (CTEPH)
c. Post-thrombotic syndrome
a. Post-PE Syndrome
This medical condition occurring after DVT/PE may subsequently cause CTEPH
a. Post-PE Syndrome
b. Chronic Thromboembolic pulmonary Hypertension (CTEPH)
c. Post-thrombotic syndrome
a. Post-PE Syndrome
This medical condition occurring after DVT/PE damages the venous valves of the leg, causing ankle/calf swelling and leg aching after prolonged standing
a. Post-PE Syndrome
b. Chronic Thromboembolic pulmonary Hypertension (CTEPH)
c. Post-thrombotic syndrome
c. Post-thrombotic syndrome
T/F: The most severe form of post-PE syndrome could cause deep skin ulcerations
F: it’s the most severe form of post-thrombotic syndrome
Trigger of acute PE and DVT
Inflammation
T/F: Type 2 DM can trigger PE or DVT
T
Most common autosomal dominant genetic mutations
Factor V Leiden and Prothrombin gene
How do Factor V Leiden and prothrombin gene influence DVT/PE?
Factor V Leiden causes resistance to activated anticoagulant protein C
Prothrombin gene increases plasma prothrombin concentration -> increased coagulation
T/F: Factor V Leiden and Prothrombin gene mutations do NOT appear to increase the risk of RECURRENT VTE
T
T/F Antiphospholipid antibody syndrome is a genetic thrombophilic disorder that predisposes to venous and arterial thrombosis
F: it is ACQUIRED
What are the three contributing factors in the formation of thrombosis (Virchow’s Triad)?
Venous stasis, hypercoagulability, endothelial injury
T/F Low oxygen tension promote venous thrombi formation
T
How does the virchow’s triad form venous thrombi?
The vascular injury and venous stasis will stimulate activated platelets (increased by hypercoagulability)»_space; activated platelets will release microparticles, which contain proinflammatory mediators that bind to neutrophils»_space; bound neutrophils will release materials and form “neutrophil extracellular traps (NET)”»_space; NET contains histones that would further stimulate platelet aggregation and promote platelet-dependent thrombin generation»_space; formation of venous thrombi
T/F: Patients suffering from VTE are more than 2x likely to have future MI or stroke
T
Since VTE, stroke, and acute coronary syndrome share similar risk factors and pathophysiology involving inflammation, endothelial injury, hypercoagulation
T/F: In PE, pressure overload in the left ventricle increases its wall tension, leading to left ventricle ischemia and dysfunction. It also dilates, compressing the adjacent normal right ventricle, resulting to its decreased CO and systemic arterial pressure»_space; circulatory collapse and death
F
The RV experiences Pressure overload
the LV gets compressed
Types of pulmonary embolism
Low-risk
Submassive (Intermediate-risk)
Massive (high-risk)
Hallmarks of massive PE
Dyspnea, hypotension, syncope, cyanosis
This type of PE has RV dysfunction despite having normal systemic arterial pressure
Submassive
Types of DVT
Lower Extremity
Upper Extremity
Superficial Venous Thrombosis (primarily not a DVT)
Most common symptom of pulmonary embolism
Unexplained breathlessness
Most common symptom of deep vein thrombosis
Cramp or “Charley horse” in the lower calf that persists and intensifies over several days
This help estimate clinical likelihood of DVT and PE
Wells point Scoring
T/F: In High DVT/PE, Blood test such as D-dimer test should be skipped
T
Should undergo diagnostic imaging tests instead
T/F In low and low-moderate PE, there are no obligatory imaging tests
T
T/F Age-adjusted dimer is NOT applicable to patients suspected of acute DVT
T
Age adjusted D Dimer is applicable to more than ___ yo and with ______ clinical probability of PE
> 50 yo; low or moderate
Standard upper limit in ng/mL of age-adjusted D dimer
500 ng/mL
formula: age x 10
Most cited ECG abnormality aside from sinus tachycardia
S1Q3T3 sign (specific but NOT sensitive)
s wave in lead I, Q wave, and an inverted T wave
Most common ECG abnormality
T wave inversion in leads V1 to V4 due to RV myocardial strain and ischemia
Principal diagnostic test for suspected DVT
Venous Ultrasonography
Primary diagnostic criterion for DVT in venous ultrasound
Loss of vein compressibility
3 Well-established xray abnormalities in PE
Westermark’s sign, Hampton’s hump, Palla’s Sign
This Xray abnormality in PE shows reduction in the pulmonary volume
Westermark’s sign
This xray abnormality in PE shows wedge-shaped density usually at the pleural base
Hampton’s Hump
This is the sign of sausage appearance in chest xray of PE due to enlarged right descending pulmonary artery
Palla’s Sign
What is the enlarged structure seen in Palla’s Sign?
(Right) descending pulmonary artery
This imaging modality is the principal imaging test for PE diagnosis
Chest CT
T RV Enlargement indicates an increase likelihood of death in 7 days
F: 30 days
Second-line diagnostic test for PE
Lung Scan (Ventilation-Perfusion Scan) for patients who cannot tolerate intravenous contrast
90% certain of PE if the ff are seen in lung scan:
Two or more segmental perfusion defects with normal ventilation (VQ Mismatch)
T/F Contrast-enhanced MRI can be used to detect large proximal, and smaller segmental/subsegmental PE
F
Unreliable for smaller segmental and subsegmental PE
Abnormal chest CT but without PE could have the following alternative diagnoses:
Pneumonia, emphysema, pulmonary fibrosis, pulmonary mass, aortic pathology
Possible other differentials in lung scan with abnormal ventilation
Asthma, COPD
T/F Echocardiography can be used in diagnosing PE
F : it would have normal results
What diseases can mimic PE in Echo?
Acute MI, pericardial tamponade, aortic dissection
Best known indirect sign of PE on transthoracic echocardiography
McConnel’s Sign - hypokinesia of RV free wall with normal or hyperkinetic RV Apex
If there’s an unsatisfactory chest CT results or plans for catheter-directed thrombolysis, this diagnostic modality is indicated
Pulmonary Angiography
T/F: Venous ultrasound is also used when lung scan for PE diagnosis is unsatisfactory
T
Chest CT: What contrast is the primary diagnostic modality for PE?
Iodine Contrast
Primary therapy for DVT
Clot dissolution that uses iodine contrast
Secondary prevention for DVT
Anticoagulation or placement of an inferior vena cava filter
Which anticoagulant is useful when hour to hour control of intensity of anticoagulation is desired?
a. UFH
b. LMWH
c. Fondaparinux
d. Warfarin
a. UFH
T/F Lab monitoring is needed when taking UFH
T
Lab monitoring is needed to target apTT of 60-80s
T/F UFH has pleiotropic effects that may decrease systemic and local inflammation
T
T/F No lab monitoring or dose adjustment is needed in using LMWH, except if obese or with CKD
T
dosing of this weight-based anticoagulant must be adjusted downwards for patients with renal dysfunction
a. UFH
b. LMWH
c. Fondaparinux
d. Warfarin
Fondaparinux
Daily therapy for at least _______ days is required for the full effect of warfarin
5 days
T/F Fondaparinux has suspected or proven heparin-induced thrombocytopenia
F
DTI (Argatroban and Bivalirudin) has HIT
This LMWH has a dosage of 1 mg/kg twice daily with normal renal function
a. Enoxaparin
b. Dalteparin
c. Tinzaparin
A. enoxaparin
This LMWH has a dosage of 200U/kg daily or 100U/kg twice daily with normal renal function
a. Enoxaparin
b. Dalteparin
c. Tinzaparin
b. Dalteparin
This LMWH has a dosage of 175U U/kg once daily with normal renal function
a. Enoxaparin
b. Dalteparin
c. Tinzaparin
c. Tinzaparin
This anticoagulant is taken 15mg twice daily for 3 weeks, followed by 20 mg once daily with dinner meal thereafter
a. Rivaroxaban
b. Apixaban
c. Dabigatran
d. Edoxaban
a. Rivaroxaban
This anticoagulant is taken 10mg twice daily for 1 week, followed by 5mg twice daily
a. Rivaroxaban
b. Apixaban
c. Dabigatran
d. Edoxaban
b. Apixaban
This is taken at 150mg twice daily after having 5 days of unfractionated heparin/LMWH/fondaparinux.
a. Rivaroxaban
b. Apixaban
c. Dabigatran
d. Edoxaban
c. Dabigatran
This is taken at 60mg once daily after having 5 days of unfractionated heparin/LMWH/fondaparinux.
a. Rivaroxaban
b. Apixaban
c. Dabigatran
d. Edoxaban
d. Edoxaban
Usual start dose of warfarin
5 mg
Antidote for heparin/LMWH hemorrhage
Protamine Sulfate
Antidote for dabigatran
Idarucizumab
Antidote for antiXa anticoagulants complications (Rivaroxaban/Apixaban)
Andexanet
Antidote for major bleeding from warfarin
Prothrombin complex concentrate
Antidote for less serious bleeding from warfarin
Fresh frozen plasma or IV Vitamin K
Minor bleeding from wrfarin or excessively high INR in the absence of bleeding
Oral vitamin K
In order of severity (antidotes)
Oral vitamin K»_space; Fresh frozen plasma or IV Vitamin K»_space; Prothrombin complex concentrate
T/F LMWH is prescribed as monotherapy for px with cancer and VTE
T
2 principal indications for IVC filter insertion
For active bleeding that precludes anticoagulation
For recurrent venous thrombosis despite intensive anticoagulation
First line vasopressor agent for treatment of PE-related shock
Norepinephrine
First line inotropic agent
Dobutamine
Fibrinolysis: administration of ____ mg rtPA as a continuous peripheral intravenous infusion over ___ hrs
100 mg; 2 hrs
This combines physical fragmentation of thrombus and catheter-directed low-dose thrombolysis
Pharmacomechanical catheter-directed therapy
Aside from fibrinolysis, ________ is an option to avert risk of major hemorrhage
Pulmonary embolectomy
Indicated for patients with CTEPH (Chronic Thromboembolic Pulmonary Hypertension)
Pulmonary Thromboendarterectomy
In-hospital prophylaxis offered for hospitalized patients to avoid VTE
low dose UFH or LMWH
This is approved as continuing prophylaxis after discharge
