Pulmonary Embolism

Question 1

What are the risk factors for a PE?

Answer 1

1 - Recent surgery

2 - Recent fracture

3 - Recent malignancy

4 - Prengancy

5 - Recent immobility

6 - Family history of PE/DVT

7 - Infection

8 - Obesity

Question 2

In order of frequency, what are symptoms of a PE?

Answer 2

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

Question 3

What are the clinical signs of a PE?

Answer 3

1 - Tachypnoea (RR > 20)

2 - Tachycardia

3 - Hypotension

4 - Evidence of DVT

Question 4

What are the initial steps that should be taken when you see a patient with suspected PE?

Answer 4

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?

Question 5

What medications that the patient may have been taking do you want to consider?

Answer 5

Anticoagulants - rivaroxaban, dabigatran, apixaban, warfarin

Question 6

After an initial general observation, what would you do next?

Answer 6

Airway assessment:

• assess their ability to speak, listen for breath sounds and look inside the mouth for any obvious obstructions

Question 7

If you feel the airway is compromised, what should you do next?

Answer 7

Put out a call for help (anaesthetists)

Perform simple airway maneouveres:

• Head tilt -chin lift
• Jaw thrust

Question 8

If the head tilt-chin lift and jaw thrust method have not improved the airway, what else can be done?

Answer 8

Nasopharyngeal airway

Question 9

Once the airway has been assessed, what next?

Answer 9

Assess Breathing:

• O2 sats aim for 94-98%
• Respiratory rate

Question 10

How should the chest be examined for a suspected PE?

Answer 10

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

Question 11

What investigations should ou carry out on a patient with a suspected PE?

Answer 11

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))

Question 12

What Well’s score indicates that a PE is likely?

Answer 12

> 4

Question 13

If the patients Well’s score is greater than 4, what should be your next step?

Answer 13

Order a CTPA

Start the patient on anticoagulants (LMWH) whilst you await CTPA

Question 14

What should you do if the Well’s score is 4 or less (PE unlikely)?

Answer 14

Perform a D-dimer test:

D-dimer -ve = PE very unlikely

D-dimer +ve = PE likely, so order a CTPA or V/Q scan

Question 15

Is a D-dimer test diagnostic for a DVT or PE?

Answer 15

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

Question 16

If the patient is contraindicated for a CTPA scan, what else can they have? And what are the contraindications for a CTPA?

Answer 16

Contraindications for CTPA - Renal impairement, contrast allergy, pregnancy

Other scans available for PE diagnosis - V/Q scan

Question 17

How should you treat someones breathing that you suspect has a PE?

Answer 17

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

Question 18

What are the signs of a massive PE, and if massive PE is suspected what should you do?

Answer 18

Signs of massive PE:

• Raised JVP
• Hypotension
• Heart failure

Question 19

How should you examine circulation in a patient with suspected PE?

Answer 19

Pulse - most likely be tachycardic

Blood pressure - pain may cause hypertension, hypotension may be a sign of a massive PE

Capillary refill time

Question 20

What blood tests should you do in the case of a suspected PE?

Answer 20

Troponin

FBC - for Hb and platelets. Also check for infection

U&E’s - check renal function (important if considering CTPA)

LFT’s

BM

Question 21

What is the most common ECG finding in cases of PE?

Answer 21

Sinus tachycardia

T wave inversion

Question 22

How should you treat someones circulation you suspect of having a PE?

Answer 22

1 - Insert 2 large bore cannulas

2 - IV fluids (NaCl 0.9% or Hartmanns)

Question 23

How do you assess ‘Disability’ in someone with a suspected PE?>

Answer 23

Check BM

Check pupils

Assess consciousness level (AVPU or GCS)