Pulmonary Embolism

Question 1

what is Pulmonary embolism (PE) ?

Answer 1

characterised by obstruction of a pulmonary artery or one of its branches usually by a blood clot which has become dislodged and been carried to the lungs by the blood stream.

Pulmonary embolism means that the material passes through the right side of the heart and lodges in the pulmonary arteries

Question 2

where do Pulmonary emboli most commonly originate?

Answer 2

in the deep veins of the lower limb, pelvis or abdomen).

90% DVT in legs

Question 3

Factors predisposing to venous thromboembolism

Answer 3

Question 4

example of embolic stuff

Answer 4

Fat, Air, Thrombus, Bacteria, Amniotic fluid, Tumor

(remember: An embolus moves like a FAT BAT)

Question 5

what do u call this appearence of lungs?

Answer 5

ground-glass appearence

this is a fat embolism after trauma of long bone

Question 6

how can air emboli to ur brain?

Answer 6

mostly through the venous die

cuz when ur standing up its a negative pressure in ur JV,

and if u have a cutt in ur JV, air can get sucked up!

Question 7

what is occuring in thr R. pulmonary A. here?

Answer 7

ventilation perfusion mismatch,

its ventilated but not perfused!

Question 8

______ commonest cause of vascular death, after myocardial infarction and stroke

Answer 8

3rd

Question 9

it is commonest cause of preventable death in hospital patients

how can we prevent it?

Answer 9

prophylactic low molecular weight heparin

give a good dose to prevent clotting

but not too high so u wont bleed!

Question 10

Risk factors for thromboembolism

Answer 10

Age > 40 years

• Surgery > 30 mins (ur body sees surgery as a trauma!)
• Obesity
• Cancer
• Prolonged immobilisation
• Previous thromboembolism

• Heart failure (stasis of blood)

• Contraceptive pill
• Pregnancy
• HRT
• Long haul travel (> 4 hrs)

• Thrombophilia

Question 11

Outcome after PE

Answer 11

Question 12

Pathophysiology of PE

Answer 12

Question 13

Symptoms of PE

Answer 13

pleuritic chest pain

SUDDEN onset breathlessness

Question 14

what is the cause for substernal chest pain in PE?

what causes fever?

Answer 14

bc RV is struggling to pump ahianst the resistence in the pulmonary vessels, mala sh3’l bl lungs!

fever: cuz of necrosis

Question 15

Main differential diagnoses

Answer 15

• MI
• Pneumothorax
• Pneumonia/pleurisy
• pleurisy
• musculo-skeletal chest pain
• Pericarditis

Question 16

Physical signs in PE

Answer 16

• Pleural rub in cases of pulmonary infarction
• Raised JVP

low Bp

Tachycardia

obvious dyspnea

look for evidence of Dvt

Question 17

what is a D dimer

Answer 17

its a Fibrin degredation product

not normally in our blood!

Question 18

Investigations and what they show

Answer 18

U&E ,FBC, baseline clotting

CXR> should be normal in PE> rules out PE

ECG> May show signs of right ventricular strain - T wave inversion in the right precordial leads (V1 - V4 and the inferior leads, II, III and aVF). The ‘classic’ finding is SI Q3 T3. Not useful as a primary diagnostic tool

ABG> may show hypoxemia & hypocapnia (cuz of hyperventilation)

D-Dimer> A normal D-dimer effectively rules out PE

Question 19

Imaging for PE

Answer 19

CT Pulmonary Angiography CTPA

Question 20

label the image,

shisalfa?

Answer 20

Saddle embolism> sits at bifurcation of P. trunk

Question 21

The poorly perfused part of the lung may undergo infarction, but usually does not do so…why?

Answer 21

because the bronchial arteries and airways continue to supply sufficient oxygen to the lung tissue.

Question 22

Treatment of low risk patients

Answer 22

Do not forget oxygen!!!

Immediate heparinisation

Question 23

How does heparinisation reduce mortality

Answer 23

1. Stops thrombus propagatio_n in the pulmonary A._ and allows the body’s fibrinolytic system to dissolve it away
2. Stops thrombus propagation at the embolic source and reduces the frequency of further PE

Question 24

Treatment of high risk patients (ex: in shock)

Answer 24

• Haemodynamic support
• Respiratory support

• Exogenous fibrinolytics (streptokinase/tPA)

– via Peripheral IV

– via Delivered directly via a _percutaneous cathete_r into the pulmonary arteries

• Percutaneous catheter directed thrombectomy
• Surgical pulmonary embolectomy

Question 25

What do we do after giving initial heparinisation

Answer 25

we give em anticoagulants!

ex: Warfarin! for 3 months!

(inhibits VK)

Question 26

What about those patients who cannot be safely anticoagulated?

give examples of those ppl and there situations that cant allow them

Answer 26

e.g have oesophageal varices, previous haemorrhagic stroke, severe thrombocytopenia

put umbrella in the vena cava

Question 27

how does Inferior Vena Cava (IVC) Filter work?

Answer 27

An inferior vena cava filter or IVC filter is a small cone-shaped device that is implanted in the inferior vena cava just below the kidneys.

bc weve got a clot downwards, we cant impant it there so we we impant it via the JV> just above renal veins> umbreall aopens up and stays there!

The filter is designed to capture an embolism,

but blood doesnt like foreign objects beong there ( bs shnsawee lazm lana some patients cannt be warfarnisd)

Question 28

Homans’ sign

Answer 28

A + Homans’s sign (calf pain at dorsiflexion of the foot) is thought to be associated with the presence of thrombosis.

Question 29

If someones reason for PE is cancer, how do we treat it?

Answer 29

long term Low molecular weight heparin

Question 30

Mx of emergency PE

Answer 30

Question 31

Thrombolysis complications

Answer 31

• Bleeding
• hypotension
• ICH or stroke
• reperfusion arryhtmias
• allergic reaction

Question 32

Thrombolysis contraindication

Answer 32

Question 33

Massive PE

Answer 33

1. Hypotension, immenient cardiac ARREST
2. signs of right heart strain on CT OR ECHO
3. Consider THROMBOLYSIS w/ Ateplase

Question 34

If patient has renal problems and needs inbestigation for PE what would u do?

Answer 34

V/Q scan