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Respiratory > Pulmonary Embolism and Hypertension > Flashcards

Pulmonary Embolism and Hypertension Flashcards

1
Q

name 2 thromboembolic diseases

A

Deep venous thrombosis (DVT)

Pulmonary embolism PE

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2
Q

d: PE

A

blockage of a pulmonary artery by a blood clot, fat, tumour or air

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3
Q

d: pulmonary infarction

A

If blood flow and oxygen to the lung tissues is compromised the lung tissue may die.

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4
Q

A thrombus in _____ is most likely to embolise

A

Proximal (Ileo-femoral)

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5
Q

A thrombus in _____ is least likely to embolise

A

Distal (Polpiteal)

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6
Q

what type of thrombus is most likely to lead to chronic venous insufficiency and venous leg ulcers?

A

Proximal (Ileo-femoral)

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7
Q

Symptoms DVT

A

Whole leg or calf involved depending on site

Swollen, hot, red, tender

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8
Q

what are differential symptoms of DVT?

A

Popliteal synovial rupture (Baker’s cyst)
Superficial thrombophlebitis
Calf cellulitis

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9
Q

How would you investigate DVT?

A

Ultrasound Doppler leg scan (1st line)

CT scan

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10
Q

What does an US leg scan exclude and why is it good?

A

popliteal cyst and pelvic mass

non-invasive

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11
Q

Symptoms of large PE

A

cardiovascular shock
low BP
central cyanosis
sudden death

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12
Q

Symptoms of medium PE

A

pleuritic pain
haemoptysis
SOB

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13
Q

Symptoms of small large PE

A

progressive dyspnoea
pulmonary hypertension
R heart failure

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14
Q

Name some risk factors for DVT and PE

A

Thrombophilia- FH, freq, site, age
Contraceptive pill (particularly if smokes), HRT
Pregnancy
Pelvic obstruction e.g. uterus, ovary, lymph nodes
Surgery e.g. pelvic, hip, knee
Immobility e.g. bed rest, long haul flights
Malignancy
Obesity
Pulmonary hypertension
Vasculitis
Trauma e.g. road traffic accident

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15
Q

Name some preventors of DVT

A

Early post-op mobilisation
TED compression stockings
Calf muscle exercises
Subcutaneous low dose low mol wt heparin perioperatively (Dalteparin- Fragmin)
Direct Oral Anticoagulant (DOAC) medication

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16
Q

name the Direct oral anticoagulant drugs given when DVT suspected and what they do?

A

Dabigatran - direct thrombin inhibitor

Rivaroxaban/Apixaban -direct inhibitor of activated factor Xa

17
Q

Findings on examination vitals and general resp exam for PE

A

Tachycardia, tachypnoea, cyanosis,
fever,
Low BP, crackles, rub, pleural effusion

18
Q

Describe ABGs in PE?

A

decreasedPaO2 decreased SaO2 (Type 1 resp failure:PaCO2 normal or low)

19
Q

is a PE a type 1/2 resp failure?

A

Type 1

20
Q

describe CXR in PE?

A

Normal early on before infarction
Basal atelectasis, consolidation.
Pleural effusion

21
Q

name the two scores used to determine PE risk?

A

Wells

Revised Geneva

22
Q

Name the investigations for PE and what expecting from them?

A

Pulmonary Embolism Severity Index (PESI)
ECG: Acute Right heart strain pattern
(S1Q3T3; T inversion in V1-3)
D-dimers usually raised
Troponin +/- BNP/pro-BNP
Isotope lung scan (Ventilation/Perfusion: V/Q
Sensitive for small peripheral emboli
Perfusion defect before infarction
Perfusion+Ventilation matched defect after infarction
CT pulmonary angiogram (CTPA) to image pulmonary artery filling defect
to pick up larger clots in proximal vessels
Consider leg and pelvic ultrasound to detect silent DVT
Echocardiogram to measure pulmonary artery pressure and right ventricular size; acute dilatation of RV in keeping with acute PE

23
Q

Which test will actually help confirm PE?

A

CT pulmonary angiogram (CTPA)

24
Q

what other things should you consider if its not PE?

A 
Consider if no obvious underlying cause
e.g. surgery /pregnancy /malignancy /immobility 
Consider cancer
Clinical exam; CXR, PSA, CA125
Pelvic USS or CT Abdo/pelvis
Autoantibodies (SLE)
Antinuclear, Anti-Cardiolipin Abs
25
Q

what test do you use If unwell with suspected intermediate to high risk PE?

A

CTPA

26
Q

what test do you use In the ambulatory setting with a low risk PE patient who has no previous respiratory disease (normal CXR)?

A

V/Q

CTPA

27
Q

what test do you use for suspected PE in pregnant woman?

A

ultrasound of legs if +ve clinical findings and assume PE if clinical supporting features OR perfusion only scan (Q scan). Reduce or avoid radiation to breast tissue where possible. However, if very unwell best modality is CTPA so accept risk of radiation to breast and baby.

28
Q

Describe how a low risk PE is managed?

A

Low risk: low PESI; -ve troponin; no oxygen; no co-morbidities
Ambulatory pathway  Home

29
Q

Describe how a high risk PE is managed?

A

with cardiovascular compromise who may require thrombolysis
BP monitoring
Medical High Dependency Unit (MHDU)

30
Q

Describe how a medium risk PE is managed?

A

ward vs MHDU

31
Q

treatment of DVT/PE?

A

Anticoagulation prevents clot propagation
tips balance to thrombolysis / body dissolves clot
Therapeutic dose of S/C Low molecular weight heparin
LMWH –Dalteparin/Fragmin
Rarely IV heparin
Empirical treatment if high clinical suspicion whilst await confirmation with investigations
If low suspicion await test results before treatment
If moderate suspicion weigh pros vs. cons. of empirical treatment
LMWH –once daily injection; no monitoring
Start warfarin simultaneously
Antagonises Vit K dependent prothrombin
Takes three days
After 3-5 days stop heparin-when INR>2

Alternatively solely use DOACs - direct oral thrombin inhibitor (dabigatran) or factor X inhibitor (Rivaroxaban/Apixaban)
less hassle and in most cases as effective as heparin/warfarin

32
Q

name some things that may interfere with treatments?

A

Alcohol, Antibiotics, Amiodarone, Cimetidine, Grapefruit…
Anti-platelets or drugs which increase bleeding tendency
Aspirin, NSAIDs, Clopidogrel

33
Q

name some treatments of PE only

A

Thrombolysis- tissue plasminogen activator (tPA) - tenecteplase
IVC filter to prevent embolisation from large ileofemoral/IVC clot - for recurrent PEs
Thrombo-embolectomy –rarely indicated
Intra-catheter directed thrombolysis
EKOS (ultrasound enhanced catheter thrombolysis)

34
Q

describe pulmonary circulation in terms of flow, pressure, normal mean pulmonary arterial pressure?

A

high flow
low pressure
mPAP is 12-20 mmHg

35
Q

what value is pulmonary hypertension?

A

25mmHg

36
Q

how is Pulmonary hypertension measured?

A

right heart catheter

37
Q

How can Systolic pulmonary arterial pressure be estimated?

A

estimated with ECHO doppler

38
Q

causes of pulmonary venous hypertension

A

Left Ventricular Systolic Dysfunction - ischaemic
Mitral Regurgitation / Stenosis
Cardiomyopathy-e.g. alcohol ,viral

39
Q

causes of primary pulmonary hypertension

A

Hypoxic – COPD , OSA , Pulmonary fibrosis
Multiple PE –chronic thromboembolic PH (CTEPH)
Vasculitis –e.g. SLE , PAN ,Systemic Sclerosis
Drugs e.g. appetite suppressants - fenfluramine
HIV
Cardiac Left to right shunt – ASD, VSD

Respiratory (27 decks)

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