Pulmonary Embolism

Question 1

What is a pulmonary embolism?

Answer 1

An obstruction in the pulmonary arterial tree

The obstruction can be:
A thrombosis (ie from a DVT)
Fat - after long bone fracture/orthopaedic surgery
Amniotic fluid
Air

Question 2

Risk factors: The wells score

Answer 2

Active cancer
Previous DVT
Recently bed ridden or surgery

Paralysis of lower extremity
Entire leg swollen
Tenderness along vein
Calf swelling 3cm greater than otherside
Pitting oedema in symptomatic leg only
Collateral superficial veins 

Alternative diagnosis more likely = -2 points

2+ points = likely

Question 3

Virchow’s triad - factors contributing to thrombosis

Answer 3

Blood stasis
Hypercoagulability
Endothelial injury

Question 4

Symptoms

Answer 4

Dyspnoea 
Pleuritic/retrosternal chest pain
Cough with haemoptysis 
Chest symptoms + DVT symptoms
Dizziness/syncope (Right Heart Failure)

Question 5

Signs

Answer 5

RR up, HR up
Hypoxia - Anxiety, restless, agitated, GCS down
Pyrexia
JVP up
Gallop heart rhythm, tricuspid regurgitation murmur
Pleural rub
Cardiogenic shock/systemic hypotension

Question 6

Diagnosis 1/2

Answer 6

Two-level wells score
CTPA if PE suspected
D-dimer if PE suspected but Wells score unlikely

Question 7

Diagnosis 2/2 the 2 level wells score

Answer 7

DVT suspected (painful leg) (3 points)
PE most likely diagnosis (3 points)
HR>100 (1.5 points)
Immobile for 3days/recent surgery (one month) (1.5 points)
Hx of DVT or PE (1.5 points)
Haemoptysis (1 point)
Malignancy (1 point)

5 points or more = PE likely

Question 8

D dimer

Answer 8

a degradation product of cross linked fibrin
Sensitive but not specific
Negative rules out PE but positive doesnt confirm it

Question 9

Management

Answer 9

Oxygen, IV access, morphine if required,
Low molecular weight heparin

Warfarin
Rivaroxaban

Check for underlying cancer

Question 10

Pregnancy

Answer 10

Most common cause of maternal death