Pulmonary Embolism

Question 1

How can a patient who has a PE present?

Answer 1

SOB
Chest pain
Haemoptysis
Tachycardia
Tachypnoea

Question 2

What is the Wells’ criteria for a PE?

Answer 2

Clinical signs and symptoms of a DVT (3)
Alternative diagnosis is less likely (3)
HR >100 (1.5)
Immobilisation >3 days or surgery >4w (1.5)
Previous DVT/PE (1.5)
Haemoptysis (1)
Malignancy (1)

Question 3

If a patient with a PE has an allergy to contrast media or renal impairment, what scan should you do?

Answer 3

V/Q instead of CTPA

Question 4

What ECG changes do you see in a PE?

Answer 4

S1Q3T2
RBBB and RAD
sinus tachycardia

Question 5

Based on the outcomes of the Well’s Criteria, what is the management?

Answer 5

PE likely: >4 points = arrange a CTPA. give LMWH if there is a delay. LMWH should be continued >5 days or until INR is 2.0

PE unlikely: 4 points or less = arrange a D-Dimer. If this is positive = CTPA

If a PE is diagnosed, continue warfarin for 3m. At 3m, re-assess.
If a PE was unprovoked, continue warfarin for >3m
If the patient has a malignancy, continue warfarin for >6m.

Question 6

What is the management of a massive PE with circulatory failure?

Answer 6

Thrombolysis

Question 7

What metabolic abnormality would you see in a PE?

Answer 7

Respiratory alkalosis

Question 8

What are the exudative causes of a pleural effusion?

Answer 8

Exudative = high protein due to INFLAMMATION

Lung cancer
Pneumonia
RA
TB

Question 9

What are the transudative causes of a pleural effusion?

Answer 9

Transudative = low protein
Related to fluid moving across into the pleural space

CCF
Hypoalbuminaemia
Hypothyroidism

Question 10

How does a pleural effusion present?

Answer 10

SOB
Dullness to percussion over the effusion
Reduced breath sounds
Tracheal deviation away from the effusion

Question 11

What are the signs of a pleural effusion on a CXR?

Answer 11

Blunting of the costophrenic angle
Fluid in the fissures
Larger effusions will have a meniscus
Tracheal deviation

Question 12

What is an empyema?

Answer 12

An infected pleural effusion
Suspect it in patients with improving pneumonia who have persisting fever

Pus, acidic pH, low glucose

Question 13

What are the investigations for a pleural effusion?

Answer 13

PA CXR
USS
Contrast CT (to see underlying cause)

Question 14

If pleural fluid showed low glucose, what could the causes be?

If pleural fluid showed raised amylase, what could the causes be?

If pleural fluid showed heavy blood staining, what could the causes be?

Answer 14

1) RA or TB
2) pancreatitis or oesophageal perforation
3) mesothelioma, PE, TB

Question 15

What is the management of a pleural effusion if systemic infectious signs are present and

1) pleural fluid is cloudy or purulent
2) fluid is clear but pH <7.2

Answer 15

Insert a chest tube for both

Question 16

What is the management of patients who have recurrent pleural effusions?

Answer 16

pleurodesis
indwelling pleural catheter
recurrent aspiration