Pulmonary Embolism Flashcards
A patient presents with chest pain worse with inspiration, dyspnea. Patient reports recent birth control use. The highest diagnosis on your differential would be what? A: pleural effusion B: pleuritis C: pulmonary embolism D: pneumothorax
C: pulmonary embolism
Answer: C (hx of venous thrombus in lower extremity MOST important indicator leading to diagnosis)
The FNP knows the most prevalent risk factors that could result in an embolus traveling to the lung include: A: Orthopedic surgery B: Vaginal Birth C: IV Drug use D: Untreated Strep Throat E: VP shunt F: all of the above G: A, B, E
F: all of the above
Answer: all of the above [air (neuro sx, central venous cath); amniotic fluid (active labor), fat (long bone fx), foreign bodies (talc injection drug users), parasite eggs (schistosomiasis), septic emboli (acute infectious endocarditis), tumor cells (renal cell carcinoma)]
T or F: Thrombus from deep veins in the upper extremities is the most common cause of pulmonary embolism
Answer: F (deep veins in the LOWER extremities; (thrombi confined to calf propagate proximally to popliteal / iliofemoral veins à break off
à embolize to pulmonary circulation)
What is an inherited disorder that presents as a risk factor for PE? A: polycythemia B: sickle cell C: thalassemia D: factor V Leiden
D: factor V Leiden
Answer: D (factor V Leiden is a mutation of one of the clotting factors in the blood. This mutation can increase your chance of developing abnormal blood clots, most commonly in your legs or lungs)
Patient presents with unilateral calf pain x3 days, increased pain with walking. Left leg appears mildly swollen. Patient appears short of breath with a HR of 115. Patient denies hemoptysis or chest pain. Patient reports no additional medical history, no recent travel.
Using the Wells Score, what result would you get? According to the Wells criteria – what clinical probability of PE does this score indicate?
Answer: Dvt symptoms (3.0), PE likely diagnosis (3.0), HR >100 (1.5) = >6.0 (high probability) – Wells Criteria, Modified Wells Criteria =
>4.0 PE likely
Using the same patient presentation above (resulting in a Wells Score of 4.5, could you utilize the PERC (Pulmonary embolism rule out criteria) protocol?
Answer: No. PERC is for patients with a Modified Wells score of <4 who meet additional criteria to rule out PE. This patient does not meet criteria therefore, PE cannot be ruled out without additional testing.
What laboratory test would be appropriate to order at this point on this patient?
Answer: CT scan (not a D-Dimer)
When assessing a patient for suspected PE - you wanted to begin by utilizing the Wells Criteria (a tool that helps to stratify the probability risk of a PE results are scored either high, moderate, low).
Modified Wells Criteria utilizes the same
questions and is scored as PE likely >4 or PE unlikely <4.
In the case of a patient who is scored >4 Modified Wells Criteria, you DO NOT NEED to order a d-dimer.
This patient is one with high suspicion for PE, and the definitive diagnostic study is a CT scan.
In the case of a patient who is scored <4 Modified Wells Criteria, you ORDER A D-DIMER. This patient is considered unlikely to have a PE.
Therefore, d-dimer is an appropriate non-invasive blood test that is helpful to rule in or out a PE in these low-risk patients.
WHY? Because if you have a low suspicion for a PE, you do a d-dimer, and its elevated. You’ve just confirmed PE and can start treatment (they were low risk and without any conditions that would falsely elevate this level).
If the d-dimer is negative, you’ve confirmed there is no PE and saved the patient from unnecessarily scanning them (radiation exposure).
R/O VTE in low-risk patients
In the emergency department, apart from clinical assessment, testing for D-dimer levels is done in order to rule out a diagnosis of VTE in low-risk patients.
Patient is determined to have a DVT. What medication regimen is appropriate for this patient?
A: Heparin Anticoagulation therapy (standard regimen) followed by 6 months of PO warfarin
A patient with cancer presents to clinic with a DVT. What medication would you order for them to go home on?
Answer: an effective drug is LMWH – recommended for patients’ w/cancer (LMWH reduced the risks of recurrent VTE by 40% with no difference in major bleeding)
What is the appropriate duration of therapy for patients with PE?
No standard – need to consider patients age, potentially reversible risk factors, likelihood and potential consequences of hemorrhage, and preferences of continued therapy (Recommendation: 3 months of anticoagulation after 1st episode provoked by sx or transient nonsurgical risk factor; Extended therapy used for an unprovoked episode with a
low-moderate risk of bleeding)
