pulmonary embolism Flashcards
what is a PE?
it is when a venous thrombus usually from the leg or pelvis enters the circulatory system, enters the right side of the heart and enters the pulmonary system
usually a blood clot
causes
immobility - bed bound, recent long flight recent surgery thrombophilia OCP pregnancy in age appropriate females leg fracture previous PE malignancy
Symptoms
pleuritic sharp chest pain SOB tachycardia fainting feverish/raised temperature haemoptysis
Pyrexia Cyanosis Tachypnoea – 90% of patients have RR >16 Tachycardia – 45% of patients Hypotension – 25% of patients Raised JVP Pleural rub Pleural effusion Look for signs that could indicate a cause – e.g. DVT, recent surgery, air travel – only 33% of patient have clinical evidence of DVT
when can the chest pain be worse?
worse with a cough
diagnostics
bloods -FBC, D dimer
ECG , echocardiogram
Doppler- US of the leg
CXR
what can be used to assess risk?
wells scores
treatment meds wise
LMW heparin
then given warfarin (for at least 3 months )
could use rivaroxaban
Anticoagulate with LMWH – e.g. dalteparin 200u/Kg/24hrs. The max dose is 18,000.
At the same time start oral warfarin 10mg
Stop the heparin when the INR is >2, and continue warfarin for a minimum of 3 months, aiming for an INR of 2-3.
You can place a vena cava filter in patients who continue to develop thrombi despite anticoagulation – but remember that implanting a filter without adequate anticoagulation will increase the risk of thrombus.
Thrombolysis may be used if the PE is deemed ‘Massive’ – 50mg alteplase – as long as no contraindications
other measures for prevention
maximise mobility /movement stop OCP -consider alternative treatment for thrombophilia compression stockings o2 if necessary to manage symptoms
what can be given to all immbolise patients
lmw heparin
first line management
if suspected based on wells score, (two or more), imaging,if not then consider d-dimer
other causes of raised D dimer
ther factors that caused an increased D-Dimer include liver disease, high rheumatoid factor, malignancy, trauma, pregnancy and recent surgery.
ECG showings
CG Changes here are common but often non-specific (e.g. T wave changes, new onset AF, RBBB right axis deviation). Such changes are seen in about 80% of patients. The most common findings are T wave inversion and sinus tachycardia. Larger emboli can cause right heart strain, which will result in the ‘classical’ S1Q3T3 pattern of ECG changes in PE, although this classic sign is actually quite rare (<20% of cases). the S1Q3T3 pattern is: S waves present in lead I Q waves present in lead III T wave inversion in lead III
what else can be raised
troponin
associated with poor prognosis
first line gold standard for diagnostics
CTPA
CT-pulmonary angiogram – a CT with contrast. This is a test that use a CT scanner and radioactive dye to look at the pulmonary circulation. Its main use is in the diagnosis of PE. It is much more sensitive and specific than VQ scan
wells score criteria
Active cancer
Treatment or palliation within 6 months
Bedridden recently >3 days or major surgery within four weeks
Calf swelling >3 cm compared to the other leg
Measured 10 cm below tibial tuberosity
Collateral (nonvaricose) superficial veins presen
