Pulmonary Embolism Flashcards
Pulmonary Embolism
Block of pulmonary artery by a blood clot, fat, tumour or air.
How does PE cause pulmonary infarction?
Blood flow & oxygen supply to lung tissues is compromised => lung tissue may die.
Cause
Usually arise from DVT in pelvis or legs
How does DVT cause PE
Clots break off & pass through veins & right side of the heart.
Classification ation
Massive (with shock or syncope), Major (with RV dysfunction), Major (with normal RV function), Minor.
DVT Classification ficaion
Proximal (Ile-femoral) & distal (popliteal)
Proximal (Ileo-Femoral)
Most likely to embolise & lead to chronic venous insufficiency & venous lung ulcers.
What DVT is more likely to embolise
Proximal: Ileo-femoral.
Risk Factors
Surgery, immobility (long-haul flight), oral contraceptive, pregnancy, pelvic obstruction, trauma, thrombophilia, malignancy, obesity, pulmonary hypertension, IV drug users, vascularise.
Virchow ‘s Triad
- Factors in vessel wall.
- Abnormal blood flow.
- Hypercoagulable blood.
Side effects of anticoagulants
Increased risk of bleeding.
Symptoms: General
Acute SOB, collapse, pleuritic, chest pain, haemoptysis, sudden death.
Signs: General
Tachycardia, tachypnoea, cyanosis, fever, low BP, crackles, pleural rub, signs of pleural effusion.
Symptoms/Signs: Large
CV shock, low BP, central cyanosis, sudden death, sustained systolic <90, sever hypoxaemia.
Symptoms/Signs: Medium
Pleuritic pain, haemoptysis, dyspnoea
Symptoms/Signs: Small/Recurrent
Progressive dyspnoea, pulmonary hypertension, right heart failure.
Symptoms: DVT
Whole leg or calf swollen, red, hot and tender.
Investigations: PE
CXR, ECG, D-diners, Isotope lung scan, CTPA, Perfusion (Q) scan, ABGs
Investigations: DVT
ultrasound Doppler leg scan, CT scan.
Early CXR
Normal
Later CXR
Basal atelectasis, consolidation & pleural effusion.
ECG
Acute right heart strain pattern & acute dilatation of RV.
D-dimers
Usually raised
Isotope lung scan
Sensitive for small peripheral embol, perfusion defect before infarction, V/Q matched defect after infarction.
When should a Perfusion (Q) scan used
If pregnant
ABGs
Decreased PaO2 & SaO2, type I Resp failure, Resp alkalosis
Management of low risk
Ambulatory pathway -> home
Management of high risk
BP Monitoring & MHDU.
Management of intermediate high risk
Ward or MHDU
Should you provide treatment before test results in low suspicion PE?
Wait for results.
Should you provide treatment before test results in moderate suspicion PE?
Weigh pros & cons
Should you provide treatment before test results in high suspicion PE?
Empirical treatment
Treatment for DVT/PE
Thrombo-embolectomy, intra-catheter directed thrombolysis, EKOS.
Treatment of Massive PE
Thrombolysis or surgery
Treatment of Major PE (with RV dysfunction)
Anticoagulants & thrombolysis
Major PE (Without RV dysfunction)
O2, thrombolysis, anticoagulants.
Prevention of DVT
Early post-op mobilisation, TED compression stockings, calf muscle exercises, subcutaneous low dose mol weight heparin peri-operatives, DOAC, IVC filter to prevent embolisation from ileofemoral clot.
Duration of Treatment for unprovoked PE
6 months
Duration of Treatment for provoked PE
3 months
Duration of Treatment of unprovoked low-risk PE
3 months
Duration of treatment of high risk proximal DVT
6 months
Duration of treatment of recurrent PE
Life-long.
