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Medical Emergencies > Pulmonary Embolism > Flashcards

Pulmonary Embolism Flashcards

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USMLE® Step 1 flashcards
1
Q

In what situation should a pulmonary embolism always be considered?

A

Sudden collapse 1-2 weeks after surgery

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2
Q

What is the mechansim of a pulmonary embolism?

A

A venous thrombi, usually from a DVT, passes into the pulmonary circulation and blocks blood flow to the lungs. The source is often occult.

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3
Q

What are the risk factors for a pulmonary embolism?

A
  • Malignancy
  • Myeloproliferative disorder
  • Anti-phospholipid syndrome
  • Surgery
  • Immobility
  • Active inflammation
  • Pregnancy
  • Combined OCP or HRT
  • Previous thromboembolism
  • Inherited thrombophilia
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4
Q

What surgery in particular increases the risk of a pulmonary embolism?

A

Pelvic and lower limb surgery

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5
Q

What are the symptoms of pulmonary embolism?

A
  • Acute dyspnoea
  • Pleuritic chest pain
  • Haemoptysis
  • Syncope
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6
Q

What are the examination signs of a pulmonary embolism?

A
  • Hypotension
  • Tachycardia
  • Gallop rhythm
  • Increased JVP
  • Loud P2
  • Right ventricular heave
  • Pleural rub
  • Tachypnoea
  • Cyanosis
  • AF
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7
Q

What makes PE following surgery far less common?

A

Thromboprophylaxis

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8
Q

Why might pulmonary embolism be hard to identify?

A
  • It may occur with no predisposing factors
  • Breathlessness may be the only sign
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9
Q

How might multiple small pulmonary emboli present?

A

Much less dramatically, with pleuritic chest pain, haemoptysis, and gradually increasing breathlessness

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10
Q

What might help the diagnosis of pulmonary emboli?

A

Looking for a source of emboli, especially DVT - is the leg swollen?

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11
Q

How is risk stratified in suspected pulmonary embolism?

A

Based upon clinical features, using Wells score

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12
Q

What investigations should be done in a patient with suspected pulmonary embolism?

A
  • U&E, FBC, and baseline clotting
  • ECG
  • D-dimer
  • CXR
  • ABG
  • CT pulmonary angiography
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13
Q

What might the ECG show in a patient with pulmonary embolism?

A

Commonly normal or shows sinus tachycardia, but might show;

  • Right ventricular strain pattern in V1-V3
  • Right axis deviation
  • Right bundle branch block
  • AF
  • Deep S waves in I
  • Q waves in III
  • Inverted T waves in III
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14
Q

What might the chest x-ray show in pulmonary embolism?

A

Often normal, but may show;

  • Decreased vascular markings
  • Small pleural effusion
  • Wedge-shaped area of infarction
  • Atelectasis
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15
Q

What might the ABG show in pulmonary embolism?

A

Hyperventilation and poor gas exchange leads to decreased PaO2, decreased PaCO2, and increased pH

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16
Q

What is the use of D-dimer?

A

In a low-probability patient, a negative D-dimer effectively excludes PE

17
Q

What is the problem with D-dimer?

A

It has low specificity, and might be increased in thrombosis, inflammation, post-operatively, and in infection

18
Q

What is the advantage of CTPA?

A

It is sensitive and specific

19
Q

What can be used if a CTPA scan is unavailable?

A

V/Q scan

20
Q

How is a large pulmonary embolism managed?

A
  1. Oxygen if hypoxic, 10-15L/min
  2. Morphine 5-10mg IV with anti-emetic if patient is in pain or very distressed
  3. IV access and start LMWH
  4. If hypotension, give 500mL IV fluid bolus and get ICU input
21
Q

How should pulmonary embolism be managed if the patient is haemodynamically stable?

A

If persistent decreased BP, consider vasopressors, e.g. dobutamine or noradrenaline. Aim for systolic BP >90mmHg

22
Q

How should pulmonary embolism be managed if the patient is haemodynamically unstable?

A

Consider thrombolysis (alteplase 10mg IB bolus, and then IVI 90mg/2h)

23
Q

What long-term treatment is required for pulmonary embolism?

A

Long-term anticoagulation using DOAC or warfarin

24
Q

Give four examples of underlying causes of pulmonary embolism

A
  • Thrombophilia
  • SLE
  • Polycythaemia
  • Malignancy
25
Q

How should malignancy be checked for in a patient who has had a pulmonary embolism?

A
  • Careful history
  • Full physical examination
  • CXR
  • FBC
  • LFT
  • Calcium
  • Urianalysis
  • Consider CT abdomen/pelvis and mammogram
26
Q

How long should a patient be on long-term anticoagulation following a pulmonary embolism?

A

If obvious remedial cause, 3 months. Otherwise, continue for 3-6 months, or longer if recurrent emboli or underlying malignancy

Medical Emergencies (10 decks)

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