Pulmonary Embolism Flashcards
What is a pulmonary embolism?
- Clot in a pulmonary artery
- Usually through embolism, often DVT
What are the risk factors for PE?
- Recent surgery
- Immobility
- Pregnancy
- Hormone therapy e.g. COCP
- Malignancy
- Polycythaemia
What VTE prophylaxis is common in the community/hospitals?
- TED Stockings
- LMWH
How does PE present?
- Dyspnoea
- Pleuritic chest pain
- Low-grade fever
- Unilateral leg tenderness
- Presence of history in risk factors
What signs might a PE show?
- Hypotension (Massive PE)
- Hypoxia
- Tachycardia
- Tachypnoea
- Unilateral leg swelling
What score is used for PE risk?
Wells Score
What are the factors in a Wells Score?
- Signs of DVT
- Tachycardia
- Recent surgery/immobility
- Previous PE/DVT
- PE the most likely diagnosis
- Haemoptysis
- Malignancy
Which factors of the Wells Score will score 3 points?
- Signs/Symptoms of DVT
- PE the most likely diagnosis/Others less likely
Which factors of the Wells Score will score 1.5 points?
- Tachycardia
- Immobilisation 3 days/Surgery last 4 weeks
- Previous DVT/PE
Which factors of the Wells Score will score 1 point?
- Malignancy treated within last 6 months or palliative
- Haemoptysis
What Wells Score indicates a likely PE?
A score greater than 4
What should you do if Wells >4?
CT PA
What should you do if Wells is less than or equal to 4?
- D-dimer
- If D-Damer is raised, then CTPA
What is a D-dimer?
- Breakdown product of fibrinogen, indicating level of clotting in the blood
- Very sensitive but not specific
What else can raise a D-dimer?
- Pneumonia
- Malignancy
- HF
- Surgery
- Pregnancy
What other investigation might be useful for PE?
VQ Scan
What is a VQ scan?
- Shows ventilation-perfusion mismatch
- Uses radioactive isotopes
What acid-base status is common in PE?
Respiratory Alkalosis
- Tachypnoea lowers CO2
- pH goes opposite way
What supportive management is used for PE?
- Oxygen
- Analgesia
- Monitor for deterioration
What initial management is used for PE?
Treatment dose LMWH e.g. dalteparin
When should the initial management be started?
Immediately
- Before confirming the diagnosis e.g. while waiting for a scan
What should you do after the initial management?
Switch to long term anticoagulation
- Warfarin
- DOAC/NOAC
- LMWH
What is the INR target for warfarin?
2-3
What should you do when switching from LMWH to warfarin?
Continue the LMWH for 5 days or until INR is 2-3 for 24 hours, WHICHEVER IS LONGER.
How long should anti-coagulation go on for?
- 3 months if there is an obvious cause (then review)
- 3-6 months if the cause is unclear, in recurrent VTEs or if there is an irreversible cause
- 6 months in active cancer (then review)
When is thrombolysis used?
In massive PE where benefits outweigh the risks.
