Pulmonary Embolism and Pneumothorax Flashcards
What condition is known as “the great Masquerader”?
Pulmonary Embolism
Pulmonary Embolism:
Obstruction of the pulmonary artery or its branches by material (thrombus, tumor, air or fat) that originated elsewhere in the body
Form of venous thromboembolism (VTE)
Common and fatal
Clinical presentation is variable and often nonspecific making the diagnosis challenging
PE Epi:
Higher in males
Incidence rises with increasing age particularly women
100,000 annual deaths in the US
Age-adjusted mortality rates for African-American adults is 50 % higher than whites
PE risk factors:
Obesity
Pregnancy
Prior history of PE
Increasing age
Inherited (factor V Leiden, prothrombin gene mutation, protein C and S, antithrombin deficiency)
Acquired (malignancy, surgery, trauma, pregnancy, oral contraceptives, HRT, immobilization,) extended travel
PE symptoms:
Dyspnea at rest or with exertion (73%) * Pleuritic chest pain (44%)* Cough (37%)* Orthopnea Calf or thigh pain and or swelling (44%) Wheezing Hemoptysis *many patients with large PE have mild or nonspecific symptoms or asymptomatic *most common presenting symptoms*
PE signs:
Tachypnea (70%) Calf or thigh swelling/edema, erythema, tenderness, palpable cords (47%) Tachycardia (30%) Rales Decreased breath sounds An accentuated pulmonic component of the 2nd heart sound Jugular venous distension Fever, mimicking pneumonia
DDx PE:
Pneumonia, asthma, chronic obstructive pulmonary disease
Congestive heart failure
Pericarditis
Pleurisy “Viral syndrome”, costochondritis, musculoskeletal discomfort
Rib fracture pneumothorax
Acute coronary syndrome
Anxiety
Laboratory Tests PE:
CBC and chemistry (nonspecific, but routinely done)
Leukocytosis, ↑ESR, ↑LDH, ↑AST
ABG (neither sensitive or specific)
PT/PTT/INR
BNP
May be useful for prognostic risk stratification of patients diagnosed with PE
Troponin
Elevated in 30-50% of patients who have a moderate to large PE; assess prognosis
D-dimer
Sensitive, but poorly specific most useful when used in conjunction with clinical suspicion to facilitate a decision to proceed with further testing
For patients whom PE is unlikely and level is < 500 ng/mL, no further testing required
For patients in whom PE is likely and is > 500 ng/mL, diagnostic imaging should be performed
* ↑ myocardial infarction, pneumonia, sepsis, cancer, postoperative state, 2nd
and 3rd trimester of pregnancy
CXR PE:
Chest radiograph
Assess for other causes of symptoms
Ventilation perfusion scan VQ, not necessary if CT is planed
Hamptons’ hump and Westermarks’ sign are rare
*should raise the suspicion for PE
S1Q3T3
PE EKG
Diagnostic algorithms
- Wells
- PERC rule-out criteria
Wells:
Risk stratifies patients for PE
Used in conjunction with D-dimer test
Clinical suspicion for PE in the patient
3 tiers (low, moderate, High) or 2 tiers (unlikely, likely)
Wells is not meant to diagnose PE but to guide workup by predicting pre-test probability of PE and appropriate testing to rule out the diagnosis
PERC rule-out Criteria:
Alternative to sensitive D-dimer testing with a low-probability assessment for PE
*best used in patients who present to the ED with dyspnea or chest pain in whom the gestalt estimate for PE is < 15 %; 8 Criteria’s
1st choice diagnostic modality for PE (with contrast is gold standard) :
CTA
if patient is renal impaired what test do you do?
VQ scan
VQ is best utilized in those with …
normal chest radiograph
Management of Hemodynamically stable patients
Clinical and laboratory assessment tools
Pretest probability testing with or without definitive diagnostic imaging
Wells score, PERC
Management of Hemodynamically unstable patients
8 % present with circulatory collapse; initial or during the course of their illness (mild hypotension to overt obstructive shock)
Restore perfusion with intravenous fluid resuscitation, vasopressor support, oxygenation, and if necessary stabilizing the airway with intubation and mechanical ventilation
PE Tx:
Respiratory support
Hemodynamic support
Intravenous fluid (IVF)
Vasopressors when adequate perfusion is not restored with IVF (norepinephrine, dopamine, epinephrine, dobutamine)
Anticoagulation: hemodynamically stable patient
Unfractionated heparin therapy
Low molecular weight heparin therapy: enoxaparin
Direct thrombin inhibitors: dabigatran; and factor Xa inhibitors: apixaban, rivaroxaban and edoxaban
Warfarin therapy: Coumadin
Inferior vena cava filter whom anticoagulation is contraindicated
Anticoagulants:
UFH initial bolus 80 U/kg IV bolus followed by initial infusion 18 U/kg/hr
LMW enoxaparin 1 mg/kg SC BID w/normal renal fxn
Rivaroxaban 15 mg PO BID x 3 weeks, followed by 20 mg QD qhs
Warfarin start 5 mg PO 5-10 days to achieve INR 2.0 - 3.0
Tx of Hemodynamically unstable pts.
Thrombolytic therapy
Embolectomy
Surgical embolectomy: thrombolysis is contraindicated
PE prognosis:
Morbidity and mortality is variable
Left untreated is associated with overall mortality up to 30% compared to 2-11% in those treated with anticoagulation
Pneumothorax:
Accumulation of air in the pleural space
Primary or secondary spontaneous pneumothorax
Traumatic pneumothorax
Tension pneumothorax
Primary Spontaneous PTX:
Rupture of apical pleural blebs; almost exclusively in smoker; tall thin male 10-30 y/o; rare > 40 y/o; develop @ rest
SxSx: dyspnea, ipsilateral pleurtic chest pain, sinus tachycardia; ipsilateral ↓ breath sounds, hyperresonance to percussion, and ↓ or absent tactile fremitus are absent ↓ chest excursion
Dx: CXR
Tx: aspiration — (not relieved than / recurrent) thoracoscopy w/stapling & pleural abrasion
Secondary Spontaneous Pneumothorax
Most common cause COPD, CF, primary or metastatic lung malignancy and necrotizing PNA
Tx: tube thoracostomy/thoracotomy w/stapling of blebs & pleural abrasion; if not good operative candidate or refuses pleurodeis
Traumatic Pneumothorax
Penetrating or non penetrating chest trauma
Tx: tube thoracostomy
Tension Pneumothorax
Usually due to mechanical ventilation or resuscitative efforts
Sx: physical exam enlarged hemithroax w/no breath sounds hyperresonance to percussion and shift of the mediastinum to the contralateral side; tracheal deviation away from the involved side
Tx: medical emergency, large bore needle 14-16G; 2nd anterior ICS midclavicular, left in place until —5th ICS midaxillary thoracostomy tube inserted
Dx: clinically before CXR
Pneumothorax
Smokers instructed to quit, recurrence rate are 50%
Avoid high altitudes: flying in unpressurized aircraft
Scuba diving should be avoided
