Pulmonary Embolism

Question 1

ECG findings

Answer 1

Most commonly - Sinus Tachycardia

RBBB

S1Q3T3

R heart strain: T wave inversion and ST depression on right ventricle and inferior leads

P pulmonale

Question 2

Clinical Features

Answer 2

chest pain: typically pleuritic
dyspnoea
haemoptysis
tachycardia
tachypnoea

loud P2 (due to right heart strain)

Question 3

Diagnosis

Answer 3

All patients with symptoms or signs suggestive of a PE should have:

• a history taken
• examination performed
• chest x-ray to exclude other pathology

If a PE is still suspected a two-level PE Wells score should be performed:

• PE likely - more than 4 points: do CTPA, if delay give LMWH
• PE unlikely - 4 points or less: do D-dimer, if raised do CTPA (and if delay for scan give LMWH)

If renal impairment or contrast allergy: do VQ scan instead

Question 4

Management

Initial

After diagnosis

Answer 4

Treatment dose LMWH

Massive PE (evidence of circulatory failure): give thrombolysis

After diagnosis:

• start warfarin within 24 hours with LMWH coverage for 5 days
• Aim for INR 2-3
• Warfarin for 3 months, but longer if unprovoked
• In active cancer: LMWH for 6 months