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Year 3: Medicine Block CARDIORESPIRATORY > Pulmonary Embolism > Flashcards

Pulmonary Embolism Flashcards

1
Q

What forms a Pulmonary Embolus?

A
  • Emboli can also occur from:
    • Tumour,
    • Fat,
    • Amniotic fluid
    • Foreign material during IV drug misuse
  • Most clots causing PE actually come from pelvic, abdominal thrombosis, axillary thrombosis, femoral DVT
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2
Q

How fatal are pulmonary emboli?

A

10% of clinical pulmonary emboli are fatal.

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3
Q

How do thrombi form?

A

Clots form as a result of combination:

  • Sluggish blood flow
  • Local injury or compression of vein
  • Hypercoagulable state.

‘Virchow’s Triad’

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4
Q

What is the pathophysiology of massive Pulmonary Embolism?

A

Acute obstruction of right ventricular outflow tract resulting in sudden collapse

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5
Q

What are clinical features of Massive PE?

A
  • Severe central chest pain (lack of coronary blood flow leading to cardiac ischaemia)
  • Shock
    • Pale and sweaty
  • Syncope may result if cardiac output transiently but dramatically reduced and death may occur
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6
Q

What are examination findings of Massive PE?

A
  • Tachypnoeic
  • Tachycardic
  • Hypotension
  • Peripheral shutdown
  • JVP raised with prominent a-wave.
  • Right ventricular heave, gallop rhythm and widely split-second heart sound
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7
Q

What is the treatment for massive PE?

A

Thrombolyisis - IV Alteplase

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8
Q

What are clinical features of Chronic Recurrent Pulmonary Embolism?

A
  • Dyspnoea
  • Weakness
  • Syncope on exertion
  • Occasionally angina
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9
Q

What are examination findings of Chronic Recurrent Pulmonary Embolism?

A
  • Right ventricular overload with right ventricular heave
  • Loud pulmonary second sound
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10
Q

What are risk factors for Pulmonary Embolism?

A
  • Surgery: abdominal/pelvic, Knee/Hip replacement, Post-operative Spell on ITU
  • Obstetric: Late pregnancy, Caesarian Section
  • Lower limb: Fracture, Varicose veins
  • Malignancy
  • Reduced Mobilitiy
  • Previous proven VTE
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11
Q

What is the disease process of a PE?

A
  • Lung tissue ventilated but not perfused producing intrapulmonary dead space and V/Q mismatch
  • Alveolar collapse occurs due to lack of surfactant and exacerbates hypoxaemia
  • Primary haemodynamic consequence is reduction in cross sectional area of pulmonary arterial bed.
  • Leads to elevation of pulmonary arterial pressure and reduction in cardiac output
  • Right ventricular ischaemia can occur as result
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12
Q

How is Right Ventricular Ischaemia detected?

A
  • Troponin levels
  • Creatine kinase levels
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13
Q

What can result from distal embolisation?

A

Pulmonary infarction

  • Alveolar haemorrhage with haemoptysis
  • Pleural inflammation
  • Effusion
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14
Q

What are clinical features of Pulmonary Embolism?

A
  • Sudden unexplained dyspnoea
  • Pleuritic chest pain
  • Haemoptysis
  • Patient may have fever
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15
Q

What are examination findings of Pulmonary Embolism?

A
  • Patient tachypnoeic with localised pleural rub and coarse crackles over area involved.
  • Patient may have fever
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16
Q

What are investigations undertaken for Pulmonary Embolism?

A
  • CT pulmonary angiography (definitive)
  • Plasma D-dimer
  • MRI
  • Chest X-ray
  • ECG
  • Blood Gases
  • Cardiac troponins and BNP
  • Radionuclide ventilation/perfusion scanning (V/Q scan)
  • Ultrasound scanning
  • Echocardiography
17
Q

What Well’s Score is required for CTPA?

A
  • Used to accurately diagnose and exclude pulmonary embolism
  • Wells Score over 5 means definite investigation
    • MRI or V/Q scan is used if contraindicated
18
Q

What does X-Ray show for a Pulmonary Embolism?

A
  • Linear atelectasis or blunting of costophrenic angle.
  • Occasionally, a wedge-shaped pulmonary infarct, abrupt cut-off of pulmonary artery or translucency of under-perfused distal zone is seen.
  • Patient with massive PE may have pulmonary oligaemia. Those with recurrent pulmonary emboli may have enlarged pulmonary arterioles with oligaemic lung fields
19
Q

What does X-Ray show on ECG?

A
  • Sinus tachycardia
  • Right atrial dilatation with tall peaked P waves in lead 2
  • Right ventricular strain with right axis deviation and right bundle branch block
  • T wave inversion in right pericardial leads
  • The ‘classic’ ECG pattern with an S wave in lead I, and a Q wave and inverted T waves in lead III (S1, Q3, T3), is rare.
20
Q

What does Blood Gases show in PE?

A

Type 1 Respiratory Failure Pattern: Significant pulmonary embolism will result in arterial hypoxemia with low arterial CO2 level so a

21
Q

When is Echo indicated in Pulmonary Embolism?

A
  1. Assess for evidence of right ventricular dysfunction and may show thrombus
  2. In chronic recurrent PE, there may be right ventricular dilatation and hypertrophy with pulmonary arterial hypertension
22
Q

What is the scoring system for Pulmonary Embolism?

A

Well’s Score Criteria

  • Clinical signs and symptoms of DVT
  • PE is #1 differential diagnosis OR equally likely
  • Heart rate > 100
  • Immobilization at least 3 days OR surgery in the previous 4 weeks -Previous, objectively diagnosed PE or DVT
  • Haemoptysis
  • Malignancy w/ treatment within 6 months or palliative
23
Q

How are decisions made based on the Well’s Score?

A

Low risk if <2 points

  • Consider D-dimer testing to rule out PE
  • If D-dimer positive, then consider CTPA
  • If D-dimer negative, consider stopping workup

Moderate risk if 2-6 points

  • Consider High sensitivity D-dimer testing or CTPA
  • If the D-dimer is negative, consider stopping workup
  • If the D-dimer is positive, then CTPA

High Risk >6

  • CTPA.
    • D-dimer is not recommended
24
Q

How is a Pulmonary Embolism managed?

A
  • High flow oxygen (60-100%) given to all patient
  • Initial anticoagulation with subcutaneous LMWH or fondaparinux or intravenous unfractionated heparin
  • Intravenous fluids and even inotropic agents to improve the pump
  • Thrombolysis therapy can improve pulmonary perfusion quicker than anticoagulation.
    • Used in unstable patient and consider in stable patients with adverse features such as right ventricular dysfunction.
25
Q

How are Pulmonary Emboli prevented?

A
  • Warfarin
  • DOAC, NOAC
  • LMWH long term for cancer patient or pregnant women
26
Q

What are some contradiction to Thrombolysis?

A

Absolute

  • Haemorrhagic or Ischaemic stroke <6months
  • CNS neoplasia
  • Recent trauma or surger
  • GI bleed <1month
  • Bleeding disorder
  • Aortic Dissection

Relative

  • Warfarin
  • Pregnancy
  • Advanced Liver Disease
  • Infective endocarditis
27
Q

What are complications to Thrombolysis?

A
  • Bleeding
  • Hypotension
  • Intracranial haemorrhage/Stroke
  • Reperfusion arrhythmias
  • Systemic embolization of thrombus
  • Allergic Reaction
28
Q

When does Plasma D-dimer increase?

A
  • Elevated in patient with thromboembolism and negative test excludes diagnosis of pulmonary embolised.
  • Elevated levels in patients with cancer, pregnant people and in hospitalized and elderly patients

Year 3: Medicine Block CARDIORESPIRATORY (28 decks)

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