Pulmonary Embolism Flashcards by Charles Cabus

Principal imaging test for the diagnosis of Pulmonary embolism. (Harrison’s 19th edition, pp 1633)

Chest CT scan with contrast

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Second line diagnostic test for Pulmonary embolism. (Harrison’s 19th edition, pp 1633)

Lung Scanning

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Most common ECG abnormality in Pulmonary embolism. (Harrison’s 19th edition, pp 1633)

T-wave inversion in leads V1 to V4 (Due to RV strain and ischemia)

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Most frequent ECG abnormality in pulmonary embolism. (Harrison’s 19th edition, pp 1633)

Sinus tachycardia
S1Q3T3
(S1 wave in lead I
Q wave in lead III
Inverted T wave in lead III)

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Specific but insensitive ECG finding in Pulmonary embolism. (Harrison’s 19th edition, pp 1633)

S1Q3T3
(S1 wave in lead I
Q wave in lead III
Inverted T wave in lead III)

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The usual cause of death in Pulmonary embolism. (Harrison’s 19th edition, pp 1632)

RV failure

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Most common gas exchange abnormality in Pulmonary embolism. (Harrison’s 19th edition, pp 1633)

Arterial hypoxemia

Increased alveolar-arterial O2 tension gradient

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Pathophysiology abnormalities in pulmonary embolism. (Harrison’s 19th edition, pp 1633)

Arterial hypoxemia
Increased alveolar-arterial O2 tension gradient
Increased pulmonary vascular resistance
Impaired gas exchange
Alveolar hyperventilation
Increased airway resistance
Decreased pulmonary compliance

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High risk for of an adverse clinical outcome in Pulmonary embolism. (Harrison’s 19th edition, pp 1634)

Hemodynamic instability
RV dysfunction (echo)
RV enlargement (CT)
Elevation of the troponin level (microinfarction)

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Good clinical outcome in pulmonary embolism with anticoagulation alone. (Harrison’s 19th edition, pp 1634)

RV function remains normal in a hemodynamically stable patient.

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Recommended initial diagnostic modality to use in patients suspected to have deep vein thrombosis. (Harrison’s 19th edition, pp 1634)

Venous ultrasound

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Primary criterion for the diagnosis of DVT. (Harrison’s 19th edition, pp 1635)

*Lack of vein compressibility (no wink sign)
Direct visualization of the thrombus (definite)
Manual calf compression causes augmentation of the Doppler flow pattern

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The best known indirect sign of Pulmonary embolism on transthoracic echocardiography. (Harrison’s 19th edition, pp 1634)

McConnell’s sign

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Hypokinesis of the RV free wall with normal or hyperkinetic motion of RV apex. (Harrison’s 19th edition, pp 1634)

McConnell’s sign

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Focal oligemia on Chest radiograph. (Harrison’s 19th edition, pp 1633)

Westermark’s sign

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Peripheral wedged-shaped density above the diaphragm on chest radiograph. (Harrison’s 19th edition, pp 1633)

Hampton’s hump

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Enlarged right descending pulmonary artery on chest radiograph. (Harrison’s 19th edition, pp 1633)

Palla’s sign

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Most common preventable cause of death among hospitalized patients. (Harrison’s 19th edition, pp 1631)

Pulmonary embolism

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Also known as chronic venous insufficiency. (Harrison’s 19th edition, pp 1631)

Postthrombotic syndrome

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Damages the venous valves of the leg and causes ankle or calf swelling and leg aching, especially after prolonged standing. (Harrison’s 19th edition, pp 1631)

Postthrombotic syndrome

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Virchow’s triad. (Harrison’s 19th edition, pp 1631)

Inflammation
Hypercoagulability
Endothelial injury

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Two most common autosomal dominant genetic mutations in VTE. (Harrison’s 19th edition, pp 1631)

Factor V leiden

Prothrombin gene mutation

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Causes resistance to the endogenous anticoagulant, activated protein C. (Harrison’s 19th edition, pp 1631)

Factor V leiden

Increases the plasma prothrombin concentration. (Harrison’s 19th edition, pp 1631)

Prothrombin gene mutation

Most severe form of postthrombotic syndrome causes? (Harrison’s 19th edition, pp 1631)

Skin ulceration

Most common acquired cause of thrombophilia and is associated with venous or arterial thrombosis. (Harrison’s 19th edition, pp 1631)

Antiphospholipid antibody syndrome

Characterized by extensive thrombosis affecting at least half of the pulmonary vasculature. (Harrison’s 19th edition, pp 1632)

Massive pulmonary embolism | Accounts for 5-10%

Hallmarks of massive pulmonary embolism. (Harrison’s 19th edition, pp 1632)

Dyspnea Syncope Hypotension Cyanosis

Characterized by RV dysfunction despite normal systemic arterial pressure. (Harrison’s 19th edition, pp 1632)

Submassive pulmonary embolism | Accounts for 20-25%

Indicates an increased likelihood of clinical deterioration in submassive pulmonary embolism. (Harrison’s 19th edition, pp 1632)

Combination of right heart failure and release of cardiac biomarkers

Constitutes about 70-75% cases of pulmonary embolism and have an excellent prognosis. (Harrison’s 19th edition, pp 1632)

Low risk PE

Usually presents with erythema, tenderness and a palpable cord and patients are at risk for extension of the thrombosis to the deep venous system. (Harrison’s 19th edition, pp 1632)

Superficial venous thrombosis

Most common symptom of DVT. (Harrison’s 19th edition, pp 1632)

Cramp or “charley horse in the lower calf that persists and intensifies over several days

Initial diagnostic evaluation for patients with low-to-moderate likelihood of DVT or PE. (Harrison’s 19th edition, pp 1632)

D-dimer

Differential diagnosis for DVT. (Harrison’s 19th edition, pp 1633)

Ruptured baker’s cyst Cellulitis Postphlebetic syndrome/venous insufficiency

Differential diagnosis for PE. (Harrison’s 19th edition, pp 1633)

``` Pneumonia, asthma, COPD Congestive heart failure Pericarditis Pleurisy: “viral syndrome”, costochondritis, musculoskeletal discomfort Rib fracture, pneumothorax Acute coronary syndrome Anxiety ```

Recommended pressure and duration of the below-knee graduated compression stockings for secondary prevention for DVT. (Harrison’s 19th edition, pp 1634)

30-40mmHg | for 2 years after the DVT episode

Contraidications to fibrinolysis in pulmonary embolism. (Harrison’s 19th edition, pp 1636)

Intracranial disease Recent surgery Trauma

The only FDA-approved indication for PE fibrinolysis. (Harrison’s 19th edition, pp 1636)

Massive PE

1st line inotropic agents for treatment of PE-related shock. (Harrison’s 19th edition, pp 1636)

Dopamine | Dobutamine

Most common for of in-hospital prophylaxis. (Harrison’s 19th edition, pp 1636)

Low dose UFH | LMWH

Duration of anticoagulation for DVT/PE. (Harrison’s 19th edition, pp 1635)

Provoked UE or calf – 3 months Provoked proximal leg DVT or PE – 3 to 6 months With cancer - indefinite Unprovked DVT - indefinite

Causes of provoked DVT. (Harrison’s 19th edition, pp 1635)

Surgery Trauma Estrogen Indwelling central venous catheter or pacemaker

Most serious adverse effect of anticoagulation. (Harrison’s 19th edition, pp 1635)

Hemorrhage

Antidote for hemorrhage from Heparin or LMWH. (Harrison’s 19th edition, pp 1635)

Protamine sulfate

Target INR for warfarin use. (Harrison’s 19th edition, pp 1635)

2.5 (range 2-3)

Initial dose for warfarin. (Harrison’s 19th edition, pp 1635)

5mg

Unfractionated heparin dosing for pulmonary embolism. (Harrison’s 19th edition, pp 1635)

80U/kg bolus then 18U/kg per hr

Blood test use in assessing the anticoagulant effect of Unfractionated heparin and target range. (Harrison’s 19th edition, pp 1635)

Activated partial thromboplastin time (aPTT) | 60-80 secs

Usually begins in the calf and propagates proximally to the popliteal vein, femoral vein, and iliac veins. (Harrison’s 19th edition, pp 1632)

Lower extremity DVT

Often precipitated by placement of pacemakers, internal cardiac defibrillators, or indwelling central venous catheters. (Harrison’s 19th edition, pp 1632)

Upper extremity DVT

Variables for clinical likelihood of DVT. (Harrison’s 19th edition, pp 1632)

Active cancer (1) Paralysis, paresis, or recent cast (1) Bedridden for > 3 days; major surgery < 12 weeks (1) Tenderness along distribution of deep veins (1) Entire leg swelling (1) Unilateral calf swelling > 3cm (1) Pitting edema (1) Collateral superficial nonvaricose veins (1) Alternative diagnosis at least as likely as DVT (-2) (Low < or = 0; Moderate 1-2; High >/= 3)

Variables for clinical likelihood of PE. (Harrison’s 19th edition, pp 1632)

Signs and symptoms for DVT (3) Alternative diagnosis less likely than PE (3) Heart rate > 100 bpm (1.5) Immobilization > 3 days; surgery within 4 weeks (1.5) Prior PE or DVT (1.5) Hemoptysis (1) Cancer (1) (high > 4)

Web-like extracellular networks that were release and formed from neutrophils that was stimulated by the proinflamatory mediators from activated platelets microparticles. (Harrison’s 19th edition, pp 1631)

Neutrophil extracellular traps

Anti Xa pentasaccharide. (Harrison’s 19th edition, pp 1635)

Fondaparinux

Indications for insertion of an IVC filter. (Harrison’s 19th edition, pp 1636)

Active bleeding that precludes anticoagulation | Recurrent venous thrombosis despite intensive anticoagulation

Common complication of IVC filters described as marked bilateral leg swelling. (Harrison’s 19th edition, pp 1636)

Caval thrombosis