Pulmonary Embolism Flashcards
What are the risk factors for a PE?
1 - Recent surgery
2 - Recent fracture
3 - Recent malignancy
4 - Prengancy
5 - Recent immobility
6 - Family history of PE/DVT
7 - Infection
8 - Obesity
In order of frequency, what are symptoms of a PE?
1 - SOB
2 - Pleuritic chest pain (caused by pleura coming into contact with infarcted lung tissue with each breath)
3 - Cough
4 - Haemoptysis (infarcted lung tissue)
5 - Dizziness or syncope
What are the clinical signs of a PE?
1 - Tachypnoea (RR > 20)
2 - Tachycardia
3 - Hypotension
4 - Evidence of DVT
What are the initial steps that should be taken when you see a patient with suspected PE?
Quick general observation
- If the patient is unconscious, check for a pulse and that they are breathing
- Perform AVPU and assess their conciouss level
- How do they look?
- How is their breathing?
What medications that the patient may have been taking do you want to consider?
Anticoagulants - rivaroxaban, dabigatran, apixaban, warfarin
After an initial general observation, what would you do next?
Airway assessment:
- assess their ability to speak, listen for breath sounds and look inside the mouth for any obvious obstructions
If you feel the airway is compromised, what should you do next?
Put out a call for help (anaesthetists)
Perform simple airway maneouveres:
- Head tilt -chin lift
- Jaw thrust
If the head tilt-chin lift and jaw thrust method have not improved the airway, what else can be done?
Nasopharyngeal airway
Once the airway has been assessed, what next?
Assess Breathing:
- O2 sats aim for 94-98%
- Respiratory rate
How should the chest be examined for a suspected PE?
1 - Auscultate both lungs to check air entry
2 - Listen for crackles or crepitations which may represent a pleural effusion
3 - Assess chest expansion and percussion for resonance/dullness
What investigations should ou carry out on a patient with a suspected PE?
ABG (low PaO2 and normal/low PaCO2)
CXR (useful for ruling out other lung pathology)
Well’s score (useful to give an indication of how likely a PE is before you get your definitive answer (CTPA))
What Well’s score indicates that a PE is likely?
> 4
If the patients Well’s score is greater than 4, what should be your next step?
Order a CTPA
Start the patient on anticoagulants (LMWH) whilst you await CTPA
What should you do if the Well’s score is 4 or less (PE unlikely)?
Perform a D-dimer test:
D-dimer -ve = PE very unlikely
D-dimer +ve = PE likely, so order a CTPA or V/Q scan
Is a D-dimer test diagnostic for a DVT or PE?
No
It can only be used to rule out the diagnosis
D-dimer might be raised if the patient has an infection, recent surgery or malignancy
If the patient is contraindicated for a CTPA scan, what else can they have? And what are the contraindications for a CTPA?
Contraindications for CTPA - Renal impairement, contrast allergy, pregnancy
Other scans available for PE diagnosis - V/Q scan
How should you treat someones breathing that you suspect has a PE?
1) Oxygen - high flow (15 litres) through non-rebreath mask and sit patient upright if they are conscious
2) Assisted ventilation - if patient is unconscious and respiratory rate is too low you can give assisted ventilation through a bag valve mask
3) PE treatment - start anticoagultion whilst awaiting CTPA scan (LWMH, Fondaparinux), also start on oral anticoagulant (Warfarin) within 24 hours of PE diagnosis and continue for 3 months
What are the signs of a massive PE, and if massive PE is suspected what should you do?
Signs of massive PE:
- Raised JVP
- Hypotension
- Heart failure
How should you examine circulation in a patient with suspected PE?
Pulse - most likely be tachycardic
Blood pressure - pain may cause hypertension, hypotension may be a sign of a massive PE
Capillary refill time
What blood tests should you do in the case of a suspected PE?
Troponin
FBC - for Hb and platelets. Also check for infection
U&E’s - check renal function (important if considering CTPA)
LFT’s
BM
What is the most common ECG finding in cases of PE?
Sinus tachycardia
T wave inversion
How should you treat someones circulation you suspect of having a PE?
1 - Insert 2 large bore cannulas
2 - IV fluids (NaCl 0.9% or Hartmanns)
How do you assess ‘Disability’ in someone with a suspected PE?>
Check BM
Check pupils
Assess consciousness level (AVPU or GCS)
