Pulmonary Embolism Flashcards
COMMS: Pulmonary Embolism
- Blockage of a blood vessel in the lung
- Usually caused by a clot forming in one of the deep veins of the leg
- This clot can get dislodged in the leg and will travel up to the heart and then be pumped into the lung blood vessels where it will get stuck when the vessels become too small to carry the clot.
What can pulmonary emboli be formed from?
- Thrombosis = usually from distant vein ==> heart ==> lodged in lungs
- Fat emboli = long bone fracture/orthopaedic surgery
- Amniotic fluid = pregnancy
- Air = following neck vein cannulation/bronchial trauma
What are the risk factors for PE
DVT RISK FACTORS
Other
- Smoking
- COPD
- CHF
- IBD
- Nephrotic syndrome
- Central venous catheterisation
- Polycaethemia vera
- Sepsis
What are the symptoms of PE?
- SOB
- Cough + haemoptysis
- Pleuritic chest pain
- Other DVT symptoms
What are the clinical features of PE?
- Tachypnoea
- Pleural rub
- Tachycardia
- Pyrexia
Others
- Raised JVP
- Gallop rhythm (widely split heart sound w/ tricuspid regurgitation murmur)
- Systemic shock & hypotension (cardiogenic)
- Hypoxia (anxiety, restlessness, agitation, decreased consciousness)
How is clinical likeliness of PE scored?
TWO LEVEL PE WELL’S SCORE
- Clinical features of DVT = 3
- Alternative diagnosis less likely than PE = 3
- HR > 100 = 1.5
- Immobilisation >3d OR Surgery last 4w = 1.5
- PHx DVT/PE = 1.5
- Haemoptysis = 1
- Malignancy = 1
How is PE WELL’S scored?
> 4 points = PE likely
4 points or less = PE unlikely
If PE unlikely what is the investigative plan?
- D-Dimer = IF POSITIVE…
THEN
- CTPA (if delayed then give LMWH)
IF PE likely what is the investigative plan?
- CTPA
IF DELAY in scan
- Give LMWH until can scan
If a suspected PE patient is allergic to the CT contrast what is the investigative plan?
V/Q perfusion scan
What are the signs of CTPA?
- Can show clots down to 5th order pulmonary arteries
- Show as partial or complete filling defects
What other investigations an suggest PE?
BLOODS
- ABG - hypoxia/hypocapnia
- D-dimer
- Troponin (if right heart strain)
IMAGING
- ECG (S1 QIII Inverted T II) / (Right axis deviation)
- CXR (band atelectasis, elevation hemidiaphragm, prominent central pulmonary artery, oligaemia at site of embolism)
What are the signs of a MASSIVE PE?
- Sustained hypotension
- Bradycardia
- Pulselessness
What is the management for PE?
Management generally same as DVT (see vascular section)
Immediate
- O2 100%
- Analgesia - morphine
- Assess circulation
- IF massive PE suspected (systolic BP <90) = thrombolysis
- OK to give alteplase w/o CTPA if suspected PE and patient arrest
-Anticoagulation should be considered to be extended beyond recommended three months if unprovoked PE/DVT attack
