Pulmonary Embolism

Question 1

What is a pulmonary embolism?

Answer 1

• Clot in a pulmonary artery

- Usually through embolism, often DVT

Question 2

What are the risk factors for PE?

Answer 2

• Recent surgery
• Immobility
• Pregnancy
• Hormone therapy e.g. COCP
• Malignancy
• Polycythaemia

Question 3

What VTE prophylaxis is common in the community/hospitals?

Answer 3

• TED Stockings

- LMWH

Question 4

How does PE present?

Answer 4

• Dyspnoea
• Pleuritic chest pain
• Low-grade fever
• Unilateral leg tenderness
• Presence of history in risk factors

Question 5

What signs might a PE show?

Answer 5

• Hypotension (Massive PE)
• Hypoxia
• Tachycardia
• Tachypnoea
• Unilateral leg swelling

Question 6

What score is used for PE risk?

Answer 6

Wells Score

Question 7

What are the factors in a Wells Score?

Answer 7

• Signs of DVT
• Tachycardia
• Recent surgery/immobility
• Previous PE/DVT
• PE the most likely diagnosis
• Haemoptysis
• Malignancy

Question 8

Which factors of the Wells Score will score 3 points?

Answer 8

• Signs/Symptoms of DVT

- PE the most likely diagnosis/Others less likely

Question 9

Which factors of the Wells Score will score 1.5 points?

Answer 9

• Tachycardia
• Immobilisation 3 days/Surgery last 4 weeks
• Previous DVT/PE

Question 10

Which factors of the Wells Score will score 1 point?

Answer 10

• Malignancy treated within last 6 months or palliative

- Haemoptysis

Question 11

What Wells Score indicates a likely PE?

Answer 11

A score greater than 4

Question 12

What should you do if Wells >4?

Answer 12

CT PA

Question 13

What should you do if Wells is less than or equal to 4?

Answer 13

• D-dimer

- If D-Damer is raised, then CTPA

Question 14

What is a D-dimer?

Answer 14

• Breakdown product of fibrinogen, indicating level of clotting in the blood
• Very sensitive but not specific

Question 15

What else can raise a D-dimer?

Answer 15

• Pneumonia
• Malignancy
• HF
• Surgery
• Pregnancy

Question 16

What other investigation might be useful for PE?

Answer 16

VQ Scan

Question 17

What is a VQ scan?

Answer 17

• Shows ventilation-perfusion mismatch

- Uses radioactive isotopes

Question 18

What acid-base status is common in PE?

Answer 18

Respiratory Alkalosis

• Tachypnoea lowers CO2
• pH goes opposite way

Question 19

What supportive management is used for PE?

Answer 19

• Oxygen
• Analgesia
• Monitor for deterioration

Question 20

What initial management is used for PE?

Answer 20

Treatment dose LMWH e.g. dalteparin

Question 21

When should the initial management be started?

Answer 21

Immediately

- Before confirming the diagnosis e.g. while waiting for a scan

Question 22

What should you do after the initial management?

Answer 22

Switch to long term anticoagulation

• Warfarin
• DOAC/NOAC
• LMWH

Question 23

What is the INR target for warfarin?

Answer 23

2-3

Question 24

What should you do when switching from LMWH to warfarin?

Answer 24

Continue the LMWH for 5 days or until INR is 2-3 for 24 hours, WHICHEVER IS LONGER.

Question 25

How long should anti-coagulation go on for?

Answer 25

• 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)

Question 26

When is thrombolysis used?

Answer 26

In massive PE where benefits outweigh the risks.