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A. MLA Map Acute and Emergency > Pulmonary Embolism > Flashcards

Pulmonary Embolism Flashcards

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1
Q

Pulmonary embolism (PE) is a potentially life-threatening condition caused by the obstruction of one or more pulmonary arteries, commonly due to a thrombus originating from deep vein thrombosis (DVT). What is the incidence of PE?

1 - 7000 cases per 100,000
2 - 700 cases per 100,000
3 - 70 cases per 100,000
4 - 7 cases per 100,000

A

3 - 70 cases per 100,000

Equally as likely in men and women

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2
Q

Pulmonary embolism (PE) is a potentially life-threatening condition caused by the obstruction of one or more pulmonary arteries, commonly due to a thrombus originating from deep vein thrombosis (DVT). At what age does the incidence of PE peak?

1 - 60-70
2 - 50-60
3 - 40-50
4 - 20-30

A

3 - 40-50

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3
Q

What is deep vein thrombosis (DVT)?

1 - blockage of an artery
2 - blood clot blocking a deep vein
3 - atherosclerotic development in a deep vein
4 - blood clot that has broken off from a fibrous cap

A

2 - blood clot blocking a deep vein

  • clot is formed by primary and secondary haemostasis
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4
Q

What is an embolism?

1 - blockage of an artery
2 - blood clot blocking a deep vein
3 - atherosclerotic development in a deep vein
4 - part of blood clot that has broken off into blood

A

4 - part of blood clot that has broken off into blood

  • original clot is formed by primary and secondary haemostasis
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5
Q

There are a number of risk factors that increase the risk of a DVT. Which of the following are NOT part of Virchows triad?

1 - circulatory stasis
2 - fatty streaks identified
3 - hypercoagulablestate
4 - endothelial injury

A

2 - fatty streaks identified

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6
Q

Virchow’s triad relates to stasis, hypercoagulable state and endothelial damage. All of the following are risk factors for PE that can cause stasis, EXCEPT which one?

1 - immobility
2 - sepsis
3 - obesity
4 - pregnancy
5 - long haul flight
6 - low cardiac output

A

2 - sepsis

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7
Q

Virchow’s triad relates to stasis, hypercoagulable state and endothelial damage. All of the following are risk factors for PE that can cause hypercoagulable state, EXCEPT which one?

1 - malignancy
2 - thrombophilia
3 - obesity
4 - pregnancy
5 - post-partum
6 - OCP
7 - Sepsis

A

3 - obesity

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8
Q

Virchow’s triad relates to stasis, hypercoagulable state and endothelial damage. All of the following are risk factors that can lead to endothelial damage, EXCEPT which one?

1 - previous DVT
2 - thrombophlebitis
3 - lower limb trauma
4 - low cardiac output

A

4 - low cardiac output

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9
Q

Pulmonary embolisms occur following the breaking off of part of a deep vein thrombus. Which 2 of the following do these typically occur in?

1 - calves
2 - abdomen
3 - neck
4 - thighs

A

1 - calves
4 - thighs

The part of the thrombus that breaks off is called an emboli

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10
Q

Emboli travel through the circulatory system, to the heart and then into the pulmonary arteries. Once in the arteries that can cause all of the following, but which is least likely?

1 - increased pulmonary vascular resistance
2 - sepsis
3 - hypoxia and ischemia
4 - inflammation in affected lung parenchyma
5 - pleuritic chest pain and SOB

A

2 - sepsis

If it was a septic embolic, this could occur, but this is least likely

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11
Q

Are all pulmonary emboli life threatening?

A
  • No

Depends on the size and location of the emboli

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12
Q

Which of the following is a pulmonary embolism most likely to cause?

1 - left sided heart strain and heart failure
2 - left sided heart strain and hypertrophy
3 - right sided heart strain and heart failure
4 - right sided heart strain and hypertrophy

A

3 - right sided heart strain and heart failure

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13
Q

The most pressing danger of shock is the interference of blood flow to the organs and soft tissue. Which of the following types of shock can a pulmonary embolism cause?

1 - obstructive shock
2 - hypovolaemic shock
3 - neurogenic shock
4 - septic shock
5 - cardiogenic shock

A

1 - obstructive shock

Can lead to sudden cardiac death

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14
Q

Which of the following does NOT make up the traditional triad symptoms of a PE?

1 - pleuritic chest pain
2 - dyspnoea
3 - bradycardia
4 - haemoptysis

A

3 - bradycardia

Tachycardia may occur, but not as common as other 3 symptoms

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15
Q

A DVT that has become a PE can cause haemoptysis (coughing up blood), why is this?

1 - heart pressure increases causing blood to enter the lungs
2 - hypoxia can damage lung tissue and cause bleeding
3 - bleeding in the lungs is due to fluid overload

A

2 - hypoxia can damage lung tissue and cause bleeding

  • coughing up blood is a way of trying to remove the blood from the lungs
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16
Q

PE can cause tachypnoea, why?

1 - low O2 so breathing increases
2 - increased O2 perfusion into blood
3 - mismatch in V/Q
4 - increased CO2 perfusion so it needs to be removed

A

3 - mismatch in V/Q
- lungs attempt to increase perfusion rates
- ventilation is occurring hut perfusion is blocked by the embolism

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17
Q

PE can cause tachycardia, why?

1 - low blood returning to the heart from the peripheries
2 - low O2 in blood so heart tried to increase blood sent to lungs
3 - high CO2 returning to the heart from the peripheries

A

2 - low O2 in blood so heart tried to increase blood sent to lungs

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18
Q

In addition to the classic triad of: pleuritic chest pain, dyspnoea and haemoptysis, all of the following can occur. But which is least likely?

1 - Bradypnea
2 - Crackles
3 - Tachycardia
4 - Fever (temperature

A

1 - Bradypnea

Tachypnea occurs as patients are struggling for breathe

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19
Q

Crackles and pleural rub may be evident on auscultation in a patient who has a PE, why?

1 - increased fluid in lungs expands them into pleural cavity
2 - increased pressure in lungs causes hyperinflation
3 - increased capillary pressure causes fluid to lead into pleural space

A

3 - increased capillary pressure causes fluid to lead into pleural space

  • PE leads to pressure changes
20
Q

To help rule out a pulmonary embolism, NICE guidelines recommend using the Pulmonary embolism rule-out criteria (PERC). How many of the following must be absent to rule out a PE (<2% chance of a PE)?

  • age ≥50 years.
  • heart rate ≥100 bpm.
  • oxygen saturation <95%
  • hemoptysis.
  • estrogen use.
  • prior DVT or PE.
  • unilateral leg swelling.
  • surgery/trauma < 4 weeks

1 - >2
2 - >3
3 - >5
4 - all of them

A

4 - all of them

If a patient has none of the PERC criteria, the change of a PE is <2%

PERC is typically performed if suspicion of PE is low (<15%)

21
Q

A 2-level PE Wells score can be calculated if a PE is suspected. Using the image below, what 2-level PE Wells score would suggest a PE?

1 - >2
2 - >4
3 - >6
4 - >8

A

2 - >4

<4 suggests PE us unlikely

The maximum score is 12.5

22
Q

If a patient is suspected of having a PE, what imaging is the gold standard for diagnosis?

1 - CT pulmonary angiogram
2 - MRI
3 - pet scan
4 - pulmonary angiogram

A

1 - CT pulmonary angiogram

23
Q

If a patient is suspected of having a PE, a CT pulmonary angiogram should be performed asap. However, if there is a delay, which 2 of the following can be given according to NICE guidelines?

1 - Dalteparin
2 - Apixaban
3 - Rivaroxaban
4 - Fondaparinux

A

2 - Apixaban
3 - Rivaroxaban

These are Direct oral anticoagulants (DOACs)

24
Q

If the CT pulmonary angiogram is performed for a suspected PE, but this is negative, what should then be performed?

1 - ultrasound of chest
2 - whole body MRI
3 - ultrasound of leg
4 - standard whole body CT

A

3 - ultrasound of leg

This would help rule out or diagnose DVT

25
Q

if a patient scores <4 on the 2-level PE Wells score, what should be performed?

1 - CT pulmonary angiogram
2 - ultrasound of the leg
3 - D-dimer test
4 - CHA₂DS₂-VASc Score

A

3 - D-dimer test

If the d-dimer is positive then perform a CTPA

26
Q

d-dimers are a byproduct of blood clots breaking down, and are suggestive of DVT and PE. Do d-dimers have a good sensitivity or specificity?

A
  • sensitivity of 95-98%

sensitivity = correctly identify people with a PE or DVT

specificity = correctly rule out people with no PE or DV

27
Q

if a patient scores <4 on the 2-level PE Wells score, a D-dimer test should be performed. What can be done whilst awaiting for the results?

1 - prescribe Apixaban or Rivaroxaban
2 - CTPA
3 - rest and reassure
4 - admit overnight in hospital

A

1 - prescribe Apixaban or Rivaroxaban

Both are are Direct oral anticoagulants (DOACs)

If d-dimer is negative, then stop DOACs

28
Q

Ventilation–perfusion (V ̇/Q ̇) isotope lung scanning is the non-invasive method of choice for diagnosing a PE. What is this approach?

  • V = air in and out of lungs
  • P = perfusion of lung tissue with blood vessels
A
  • phase 1 - technetium-labelled albumin aggregates are injected intravenously and blood flow to the lungs is assessed
  • phase 2 - patients inhale radiolabelled xenon or technetium to assess air delivery to the lungs.
  • can only be performed if there is a normal chest X-ray
  • sensitivity of around 75% and specificity of 97%
29
Q

Which 2 of the following, in a patient with suspected PE would rule out their ability to have a CT pulmonary angiogram, meaning they have to have a Ventilation–perfusion (V ̇/Q ̇) isotope lung scan instead in order to try and diagnose the PE?

1 - hepatic disease
2 - renal disease
3 - sickle cell disease
4 - allergic to contrast

A

2 - renal disease
4 - allergic to contrast

30
Q

In patients with suspected PE, a chest X-ray is always performed to rule out other pathophysiology. Are X-rays of patients with a PE typically normal or abnormal?

A
  • typically normal
31
Q

If we suspect a pulmonary embolism (PE), which 2 of the following may be present on an ABG that would increase our suspicion of a PE?

1 - low PaO2
2 - high PaO2
3 - low PaCO2
4 - high PaCO2

A

1 - low PaO2
- cannot get air in
3 - low PaCO2

  • CO2 is low due to rapid breathing
  • may also see a respiratory alkalosis due to low CO2
32
Q

If a patient has a pulmonary embolism, which of the following does NOT typically occur on an ECG?

1 - S1, Q3, T3 changes
2 - tachycardia
3 - ST elevation
4 - RBBB
5 - right ventricular strain

A

3 - ST elevation

S1Q3T3

The S1, Q3, T3 changes are rare
- SI = large S waves in lead I
- QIII = deep Q wave in lead III
- TIII = inverted T wave in lead III

33
Q

Brain natriuretic peptide (BNP) is a peptide released when the heart is stressed, generally due to too much filling. Can BNP be raised in a pulmonary embolism?

A
  • yes

PE can cause right sided heart strain and heart failure. Additional strain/stress on heart can raise BNP

34
Q

Troponin is an enzyme in cardiac and skeletal muscle. If the muscle is damaged this can lead to an increase in circulating troponin, which is what we can see in an MI. Can troponin be raised in a pulmonary embolism?

A
  • yes
35
Q

Echocardiograms can be performed on patients with suspected pulmonary embolism (PE). Which 2 of the following are we most likely to see on the echocardiogram in a patient with a large PE?

1 - pulmonary hypertension
2 - left ventricular dilation
3 - right ventricular dilation
4 - right ventricular contraction

A

1 - pulmonary hypertension
3 - right ventricular dilation

PE can cause right sided heart strain, leading to dilation and heart failure

36
Q

Pulmonary embolism (PE) should always be considered in a patient with pleuritic chest pain. Which of the following is NOT a typically differential for a PE?

1 - pneumothorax
2 - acute MI
3 - exacerbation of asthma
4 - community acquired pneumonia
5 - infective endocarditis
6 - left ventricular failure
7 - costochondritis

A

5 - infective endocarditis
- typically causes central chest pain, non-pleuritic

37
Q

Prior to starting patients on anti-coagulant medication, all of the following must be assessed, but which is least likely to be essential?

1 - liver function
2 - thyroid function
3 - clotting profile
4 - renal function
5 - FBC

A

2 - thyroid function

If PE suspicion is high, take blood and start anti-coagulant medication and amend based on the results

38
Q

Which 2 of the following are 1st line medications for patients with a confirmed or high clinical suspicion of PE?

1 - Dalteparin
2 - Apixaban
3 - Rivaroxaban
4 - Fondaparinux

A

2 - Apixaban
3 - Rivaroxaban

Both are direct anti-coagulants

39
Q

In a confirmed diagnosis of PE, how long should Apixaban or Rivaroxaban (DOACs) typically be given for?

1 - 7 days
2 - 4 weeks
3 - 3 months
4 - 12 months

A

3 - 3 months

This is 3-6 months for active cancer

Following this time, patients are reviewed for potentially stopping or continuing DOAC

40
Q

Apixaban or Rivaroxaban (DOACs) are 1st line for patients with PE. If these are unsuitable, which 2 of the following can be offered?

1 - enoxaparin
2 - dalteparin
3 - fondaparinux
4 - clopidogrel

A

1 - enoxaparin
2 - dalteparin

Both are LMWH

Following this dabigatran should be given

41
Q

If a patient has active cancer, which 2 of the following should be used to treat confirmed PE?

1 - Dalteparin
2 - Apixaban
3 - Rivaroxaban
4 - Fondaparinux

A

2 - Apixaban
3 - Rivaroxaban

42
Q

If a patient has significant renal impairment, which 2 of the following should be used to treat confirmed PE?

1 - Dalteparin
2 - Apixaban
3 - Enoxaparin
4 - Fondaparinux

A

1 - Dalteparin
3 - Enoxaparin

Both are Low molecular weight heparins

43
Q

If a patient has a confirmed pulmonary embolism or a massive thrombolysis, they can be treated with which 2 of the following medications?

1 - Dabigatran
2 - Alteplase
3 - Tenecteplase
4 - Dalteparin

A

2 - Alteplase
3 - Tenecteplase

  • both are Tissue plasminogen activator (tPA)
  • streptokinase can also be used
44
Q

Alteplase and Tenecteplase are both issue plasminogen activators (tPA) that are able to break clots in when a patient has a pulmonary embolism. What time frame does this need to be performed in though?

1 - <2.5h
2 - <4.5h
3 - <6.5h
4 - <8.5h

A

2 - <4.5h

45
Q

What can be offered to patients if they have recurrent PEs?

1 - lifelong DOAC use
2 - lifestyle modification
3 - leg amputation
4 - inferior vena cava (IVC) filters

A

4 - inferior vena cava (IVC) filters

A. MLA Map Acute and Emergency (42 decks)

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