Pulmonary Embolism

Question 1

a PE is obstruction of the pulmonary artery or one of its branches by material (___, ___, ___ or ___)

Answer 1

thrombus, tumour, air or fat

Question 2

T/F pulmonary thromboembolism is more common in men

Answer 2

true. slightly more common in men and rises with age. early diagnosis/treatment is essential

Question 3

T/F pe often occur in the saphenous vein

Answer 3

false. PE origins from deep veins in leg. not from superficial veins like varicose or saphenous.

Question 4

risk factors of PE

Answer 4

1. immobilization (hospitalization, air travel)
2. surgery
3. active malignancy
4. hormone use/pregnancy
5. pervious DVT/PE
6. Heavy smoking
7. Obesity
8. Coagulation abnormalities like factor V leiden mutation
9. older age.]

BUT: up to 50% of first time PE’s are unprovoked

Question 5

presenting symptoms in PE and presenting signs

Answer 5

symptoms: dyspnea, pleuritic chest pain, cough, small volume hemoptysis
signs: often none. Tachypnea, tachycardia, Right sided S4; loud P2 (pulmonary artery is blocked so there is more turbulent P2 sound), pleural rub, fever.

Question 6

what two heart sounds might you hear in someone with a PE

Answer 6

Right sided S4; loud P2 (pulmonary artery is blocked so there is more turbulent P2 sound),

Question 7

initial tests if you suspect PE

Answer 7

Question 8

why would someone in a PE have hypocarbia/respiratory alklaosis

Answer 8

It is fairly common for patients with a PE to have respiratory alkalosis initially. It is in most part because of the hyperventilation/tachypnea.

Question 9

what might you see on EKG to point you to PE?

Answer 9

1. sinus rhythm
2. new onset atrial fibrillaton

3. inverted T waves over precordium –> RV STRAIN

Question 10

2 key chest Xray findings of PE

Answer 10

1. hamptons hump + pleural effusion
2. westermark sign; very few markings of vessels.

Question 11

when to do D dimer

Answer 11

d dimer only useful if you still think this person has PE despite having low pretest probability because of lower Wells score.

D dimer has poor specificity. but it is good to rule out PE/DVT since it has high sensitivity in patients with low pretest probability.

Question 12

note: they must have ALL of the following in order to completely rule out PE.

Question 13

factors of wells score

Answer 13

1. signs and symptoms of DVT: leg swelling and pain with palpation in deep vein reigon
2. pulse >100
3. immobilization
4. previous DVT or PE
5. hemoptysis
6. malignancy
7. PE as likely or more likely than an alternative diagnosis.

Question 14

When is a VQ scan commonly used to diagnose PE ?

Answer 14

 Renal insufficiency

 Contrast allergy

 Pregnant women

 In some institutions a V/Q requires less radiation than a CT scan
Clinical Pearl - V/Q has a high sensitivity and specificity in patients with a normal Chest Xray

Question 15

what is the arrow pointing to?

Answer 15

an intraluminal filling defect from acute PE

Question 16

3 initial anticoagulation options for PE

Answer 16

1. LMWH
2. DOACS (not for patients with renal insufficinecy or pregnancy)
3. IV unfractionated heaprin in selected patients – those with increased risk for bleeding, hypotension/massive PE, renal failure.

Question 17

2 forms of chronic anticoagulation

Answer 17

Question 18

treatment of massive PE

Answer 18

• ICU setting required
• systemic thrombolysis
• catheter directed techniques
• surgical embolectomy.

Question 19

___ ___ ___ ____ may occur in 3% of all PEs due to incomplete PE esolution. Causes the formation of fibrous blockages in pulmonary arteries and can thus cause right sided heart strain

Answer 19

chronic thromboembolic pulmonary hypertension.