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2nd year > Pulmonary embolism > Flashcards

Pulmonary embolism Flashcards

1
Q

what is a PE?

A

common complication of VTE
usually from DVT
clot becomes lodged in pulmonary circulation

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2
Q

what is a PE?

A

common complication of VTE
usually from DVT
clot becomes lodged in pulmonary circulation

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3
Q

what are the causes of PE?

A

fat
amniotic fluid
blood clot
air - iatrogenic

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4
Q

what are the risk factors?

A 
age
malignancy
infection 
family history 
immobility 
pregnancy 
previous DVT/embolism
oestrogen therapy - HRT and COCP
trauma 
surgery 
recent MI
dehydration 
smoking 
congestive heart failure 
antithrombin deficiency
protein C deficiency
inherited clotting deficiencies 
obesity 
varicose veins
recent air travel 
AF
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5
Q

immobility

A

> 24 hours of bed rest
48 hours of immobility
plaster of paris over limb

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6
Q

pregnancy

A

oestrogen increases risk of PE

risk highest 4 weeks postpartum

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7
Q

clinical features of PE

A

wide range

asymptomatic - death

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8
Q

signs of PE

A 
pyrexia
cyanosis
tachypnoea - >16 
tachycardia
hypotension
raised JVP
pleural rub 
pleural effusion 
AF
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9
Q

symptoms of PE

A 
pleuritic chest pain - worse of inspiration 
breathlessness
cough
haemoptysis 
dizziness 
syncope 
non-pleuritic chest pain 
SOB
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10
Q

diagnosis

A

PERC score
Wells score
D-dimer

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11
Q

what else can increase D-dimer?

A 
liver disease 
high rheumatoid factor
malignancy 
trauma 
pregnancy
recent surgery
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12
Q

normal D-dimer

A

<0.5

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13
Q

CXR

A

excludes other causes
often normal
may show pulmonary oedema, atelectasis

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14
Q

atelectasis

A

little areas of collapsed lung due to blood loss

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15
Q

ECG

A 
non-specific changes
common to see some changes
most common = sinus tachycardia 
T wave inversion 
right heart strain 
S1Q3T3
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16
Q

what is S1Q3T3?

A

S waves in lead 1
Q waves in lead III
T wave inversion in lead III

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17
Q

CTPA

A

CT-pulmonary angiogram
radioactive dye
diagnostic of PE
more sensitive and specific than VQ scan

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18
Q

when is VQ scan used over CTPA?

A

CTPA is highly radiating so VQ is better in young, pregnant females

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19
Q

VQ scan

A

negative has very high negative predictive value but positive scans are less useful

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20
Q

ABG results

A

low O2
CO2 normal or low due to hyperventilation
metabolic acidosis
cannot exclude PE

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21
Q

troponin

A

raised in 20-40% of PE patients due to extra stress and stretch on right ventricle
higher = worse prognosis

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22
Q

echo

A

look for RV strain and dilatation

right ventricular dysfunction = predictor of mortality

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23
Q

treatment

A 
anticoagulation with LMWH
oral warfarin 
vena cava filter 
thrombolysis if massive 
embolectomy
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24
Q

anticoagulation doses for PE treatment

A

200u/kg/24 hours of dalteparin (18,000 = max dose)
start oral warfarin - 10mg at same time
stop heparin when INR >2
continue warfarin for min of 3 months, aiming for INR of 2-3

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25
Q

when to fit a vena cava filter?

A

when patients continue to develop thrombi despite anticoagulation

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26
Q

thrombolysis

A

50mg alteplase

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27
Q

what are the causes of PE?

A

fat
amniotic fluid
blood clot
air - iatrogenic

How well did you know this?
1
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2
3
4
5
Perfectly
28
Q

what are the risk factors?

A 
age
malignancy
infection 
family history 
immobility 
pregnancy 
previous DVT/embolism
oestrogen therapy - HRT and COCP
trauma 
surgery 
recent MI
dehydration 
smoking 
congestive heart failure 
antithrombin deficiency
protein C deficiency
inherited clotting deficiencies 
obesity 
varicose veins
recent air travel 
AF
How well did you know this?
1
Not at all
2
3
4
5
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29
Q

immobility

A

> 24 hours of bed rest
48 hours of immobility
plaster of paris over limb

How well did you know this?
1
Not at all
2
3
4
5
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30
Q

pregnancy

A

oestrogen increases risk of PE

risk highest 4 weeks postpartum

How well did you know this?
1
Not at all
2
3
4
5
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31
Q

clinical features of PE

A

wide range

asymptomatic - death

32
Q

signs of PE

A 
pyrexia
cyanosis
tachypnoea - >16 
tachycardia
hypotension
raised JVP
pleural rub 
pleural effusion 
AF
33
Q

symptoms of PE

A 
pleuritic chest pain - worse of inspiration 
breathlessness
cough
haemoptysis 
dizziness 
syncope 
non-pleuritic chest pain 
SOB
34
Q

diagnosis

A

PERC score
Wells score
D-dimer

35
Q

what else can increase D-dimer?

A 
liver disease 
high rheumatoid factor
malignancy 
trauma 
pregnancy
recent surgery
36
Q

normal D-dimer

A

<0.5

37
Q

CXR

A

excludes other causes
often normal
may show pulmonary oedema, atelectasis

38
Q

atelectasis

A

little areas of collapsed lung due to blood loss

39
Q

ECG

A 
non-specific changes
common to see some changes
most common = sinus tachycardia 
T wave inversion 
right heart strain 
S1Q3T3
40
Q

what is S1Q3T3?

A

S waves in lead 1
Q waves in lead III
T wave inversion in lead III

41
Q

CTPA

A

CT-pulmonary angiogram
radioactive dye
diagnostic of PE
more sensitive and specific than VQ scan

42
Q

when is VQ scan used over CTPA?

A

CTPA is highly radiating so VQ is better in young, pregnant females

43
Q

VQ scan

A

negative has very high negative predictive value but positive scans are less useful

44
Q

ABG results

A

low O2
CO2 normal or low due to hyperventilation
metabolic acidosis
cannot exclude PE

45
Q

troponin

A

raised in 20-40% of PE patients due to extra stress and stretch on right ventricle
higher = worse prognosis

46
Q

echo

A

look for RV strain and dilatation

right ventricular dysfunction = predictor of mortality

47
Q

treatment

A 
anticoagulation with LMWH
oral warfarin 
vena cava filter 
thrombolysis if massive 
embolectomy
48
Q

anticoagulation doses for PE treatment

A

200u/kg/24 hours of dalteparin (18,000 = max dose)
start oral warfarin - 10mg at same time
stop heparin when INR >2
continue warfarin for min of 3 months, aiming for INR of 2-3

49
Q

when to fit a vena cava filter?

A

when patients continue to develop thrombi despite anticoagulation

50
Q

thrombolysis

A

50mg alteplase

51
Q

what is paradoxical embolism?

A

embolism that travels through heart defect and can cause stroke
travels from vein to artery
can cause stroke

52
Q

complications of PE

A 
recurrence
cardiac arrest
pleural effusion
pulmonary infarction 
arrhythmia - AF
pulmonary hypertension 
heart failure
abnormal bleeding due to anticoagulants 
embolectomy complications
53
Q

prognosis

A

most risk of mortality if the first few hours after embolism
high risk of another PE within 6 weeks of initial one
most people make full recovery if treated promptly
existing serious illness can cause poorer prognosis

54
Q

differential diagnoses

A
  • acute coronary syndrome
  • pleuritic chest pain – pneumonia
  • pericarditis
  • MSK back pain
  • other embolus – fat, amniotic fluid or air
  • dissecting aortic aneurysm
  • anxiety
  • syncope of another cause
  • exacerbation of COPD
55
Q

PERC

A

PE rule-out criteria

56
Q

PERC scoring

A

0 = <2% chance of PE as long as there are no clinical signs
positive factors needs further work up
each factor gives 1 point

57
Q

what are the PERC factors?

A 
>50 years old 
HR >100 
SaO2 >95% on room air
unilateral leg swelling 
haemoptysis 
recent surgery or trauma 
previous PE/DVT 
exogenous oestrogen
58
Q

gold standard DVT investigation

A

venography

59
Q

other diagnostics

A 
D-dimer 
leg measurement 
ultrasound (higher sensitivity above knee) 
venometer 
doppler ultrasound 
fibrinogen testing 
S1Q3T3
60
Q

epidemiology of DVT

A

25-50% of all surgical patients
more common in veins due to slower blood flow
can occur in any vein more common in legs and veins

61
Q

causes of DVT

A 
stasis/ immobility - hospital bed, long flight 
dehydration 
oestrogen - pregnancy, COCP, HRT 
genetic clotting defect - protein C deficiency 
obesity - atherosclerosis 
age 
varicose vein 
surgery
previous DVT/ embolism 
trauma 
infection 
malignancy
62
Q

what is virchow’s triad of risk factors?

A

stasis
hypercoagulability
vessel wall injury

63
Q

signs/ symptoms of DVT

A 
red, swollen leg
tenderness
pitting oedema 
fever 
horman's sign 
well's score 
pain
64
Q

horman’s sign

A

increased resistance/pain on forced foot dorsiflexion

don’t do this test as it can dislodge the clot

65
Q

pathology of DVT

A

clot develops at site of damage to vessel wall - atherosclerotic plaque or site of trauma
impairs venous leg drainage

66
Q

clinical diagnosis of DVT

A

highly unreliable
50%
coupled with D-dimer = 80%

67
Q

treatment of DVT

A 
prevention is best
LMWH 
warfarin 
bed rest 
elasticated stockings 
IVC filter 
thrombolysis
68
Q

anticoagulation for DVT

A

ASAP LMWH and continued for 5 days minimum
stop LMWH when INR = 2-3
6 weeks of LMWH for patients with below knee DVT
start warfarin at same time

69
Q

benefit of elasticated stockings

A

reduces risk of superficial thrombphlebitis

70
Q

IVC filter

A

used if anticoagulation fails

71
Q

continuation of warfarin

A

6 months if 1st DVT
3 months if first DVT and occurred post-op
permanently if recurrent DVT or there is a genetic clotting disorder or other large risk factors

72
Q

prognosis for DVT

A 
recurrence depends on risk factors
if post-op when first experienced recurrence is unlikely 
5 year recurrence = 30% 
risk of PE fatality = 3% 
often self-resolves
73
Q

complications of DVT

A 
PE
post-phlebitic syndrome
ulcers
pain 
skin colour changes
sudden death from PE
74
Q

How to prevent DVT?

A 
stop pill 4 weeks pre-op 
mobilise early post-op
pre-op LMWH 
stay active 
maintain a healthy weight
hydration
75
Q

how to prevent PE?

A 
treat DVTs
anticoagulation 
compression stockings 
keep active - post-op, long haul flights 
stop smoking 
regular exercise 
not sitting for long time 
healthy balanced diet 
healthy weight maintenance 
reducing DVT risk
76
Q

differential diagnoses for DVT

A

ruptured Baker’s cyst
lymphadenopathy
superficial thrombophlebitis
injury - muscle haematoma

77
Q

what is pitting oedema?

A

observable swelling of body tissues due to fluid accumulation
causes indentation that persists some time after release of pressure.
Associated with retention of sodium and occurs when more than 3 litres of interstitial fluid collects.

2nd year (48 decks)

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