Pulmonary embolism (Complete)

Question 1

What are the main signs/symptoms of pulmonary embolism? (5)

Answer 1

Chest pain (Pleuritic)

Tachyponoea

Tacchycardia

Dyspnoea

Haemoptysis

Question 2

What associated symptoms can also present in patients with PE? (4)

Answer 2

Fever

Cough

Retrosternal chest pain (due to RV failure)

Dizziness or syncope (In severe cases)

Question 3

Pulmonary embolism should always be suspected in patients presenting with signs/symptoms of which other condition?

Answer 3

DVT

Question 4

What risk factors increase likelihood of having a PE? (5)

Answer 4

History of DVT or previous PE

Pregnancy

Oestrogen use (e.g. HRT, OCP)

Active cancer

Recent surgery

Question 5

What findings on respiratory examination can point towards a PE? (5)

Answer 5

Can have normal resp findings

Crepitations on asucultation

Pleural rub

Hypoxia

Hypotension

Question 6

What scoring system can be used to aid suspicion of PE?

Answer 6

Wells Score

Question 7

What Wells Score suggests the diagnosis of a PE is likely?

Answer 7

> 4

Question 8

What other differentials should be considered in patients suspected of having a PE?

Answer 8

Respiratory causes of symptoms: Pneumothorax, Pneumonia

Cardiovascular causes of symptoms: ACS, Heart failure

Question 9

What investigations should be ordered for patients suspected of having a PE? (4)

Answer 9

Bedside:
ECG (Can indicate right ventricular dysfunction suggestive of PE)

Bloods:
ABG: Normal or Type I respiratory failure
FBC: Check for anaemia due to haemoptysis
U&Es: Assess renal function before CTPA as renal failure is contraindiction.
Clotting studies: INR, PT and aPTT as they are needed to establish baseline for anticoagulation.
D-dimer (elevated): Useful in ruling out a PE if low clinical suspicion.

Imaging:
CTPA [diagnostic]
CXR (rules out other causes if normal)

Question 10

What scoring system can be used to measure risk of PE?

Answer 10

Well’s scoring system

> 4: Requires further imaging. Patient should be given LMWH whilst awaiting results.

<4: Measure D-dimer to exclude PE

Question 11

What scoring system can be used to exlude PE?

Answer 11

PERC (Pulmonary embolism rule-out criteria)

Question 12

What findings on investigation is diagnostic of PE?

Answer 12

Positive CTPA

Question 13

If CTPA is negative but there is still concern over risk of PE, what investigation should be conducted?

Answer 13

Proximal leg ultrasound to rule out DVT if suspected

Question 14

If a PE is unlikely based on Well’s score of < 4 or PERC, what investigation should be conducted to rule out PE?

Answer 14

D-dimer (would be elevated if PE)

N.B. CTPA only ordered if PE is likely

Question 15

What should always be done whilst awaiting for CTPA or D-dimer results in patients suspected of PE?

Answer 15

Interim anticoagulation

E.g. LMWH

Question 16

What ECG findings can present in patients with PE?

Answer 16

S1Q3T3

S1: Large S-wave on lead I

Q3: Large Q wave in lead III

T3: Inverted T wave in lead III

N.B. This is SPECIFIC for PE but not sensitive. In most cases you will probably just see tachycardia

Question 17

What are common CXR findings in patients with PE?

Answer 17

Normal CXR

Question 18

What is the acute management plan for PE?

Answer 18

ABCDE approach:
A: Likely patent
B: Give oxygen if sats low
C: IV fluid if systolic is <90mmHg
D: Likely unremarkable
E: Check for signs of DVT. Patients may also have low-grade fever.

If patient is haemodynamically unstable (e.g. worsening chest pain, resp distress, hypotension, confusion) This indicates a severe PE. Patient need IV bolus of ateplase (THROMBOLYSIS)

Question 19

What is the management plan for all patients diagnosed with PE?

Answer 19

Anticoagulation therapy for at least 3 months [3-6 for active cancer]

DOAC (direct-oral anticoagulation)

Question 20

What type of anticoagulation therapy is reccomended for patients with PE? Give 4 examples of medications.

Answer 20

DOAC (Direct oral antocoagulation)

Apixaban

Dabigatran

Edoxaban

Rivaroxaban

Question 21

Treatment of PE with DOAC is contraindicted in which types of patients? What should be given instead?

Answer 21

Severe renal impairment

Anti-phospholipid syndrome

Give low-weight molecular heparin instead

Question 22

What additional treatment option should be first line in patients with severe PE (circulatory failure such as hypotension)?

Answer 22

Thrombolysis (uses medications or a minimally invasive procedure to break up blood clots and prevent new clots from forming)

Typically IV bolus of ateplase

Question 23

What medication is given in acute management of a patients with signs of severe PE?

Answer 23

IV bolus of ateplase

Question 24

What management plan should be considered in patients in which anticoagulation is contraindicted or in patients with reccurent DVTs on warfarin?

Answer 24

Inferior vena cava filter

Question 25

When would an embolectomy be considered?

Answer 25

In patients with massive PE and thrombolysis is contraindicted