pulmonary embolism lms Flashcards

1
Q

presentation of PE

A

acute - within minutes of pulmonary arterial occlusion
subacute - days to weeks, sometimes due to multiple small PEs
chronic - CTEPH

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2
Q

CTEPH

A

chronic thromboembolic pulmonary hypertension
one of the causes of chronic pulmonary hypertension
very insidious course
average delay is usually over a year

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3
Q

symptoms of PE

A

non specific
breathlessness
chest pain - may be central and mimic MI
syncope/collapse or feeling of impending collapse often on exertion
pleuritic chest pain and haemoptysis - not common

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4
Q

signs of PE

A

may be none
may be in cardiovascular collapse - with raised HR, raised RR, drop in BP
swollen calf - if DVT present
raised JVP but difficul;t to elicit
pleural friciton rub or localised crackles
hypoxaemia on pulse oxymetry - may be normal at rest but desat on exertion

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5
Q

how can you ellicit hypoxic signs

A

walk your patient around the ED with a pulse oximeter on and see if they desat

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6
Q

risk factors

A

active cancer - may be undiagnosed at presentation
immobility - chronic medical problemss or post op or ICU
lower limb/pelvic surgery
previous VTE
thrombophilia
pregnancy/puerperium

air travel/oestrogen therapy

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7
Q

wells criteria

A

clinical assessment for pulmonary embolism
includes:
- clinical symptoms of DVT (leg swelling, pain on palpation)
- other diagnosis less likely than pulmonary embolism
- heart rate
- immobilisation
- previous DVT/PE
- haemoptysis
- malignancy

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8
Q

massive PE

A

also called high risk PE
one that is immidiately life threatening
drop in systolic to under 90 or drop in BP of over 40 or more for more than 15 minutes with no other cause
caardiopulmonary arrest

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9
Q

submassive PE

A

intermediate risk PE
does not cause haemodynamic compromise
acutd right ventricular dysfunction demonstrated on ECHO but not haemodynamically unstable

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10
Q

D dimer

A

not specific
often positive in unwell immobile patients
only useful if negative in a low risk patient to rule out DVT or PE
not indicated if there is a risk factor present

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11
Q

when should you skip using the d dimer test

A

if there is a risk factor present, or symptoms duggestive of possible PE or if they score high enough on the Wells criterica
then just go straight to the diagnostic test

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12
Q

ECG findings

A

usually not helpful
findings are usually non specific
sinus tachycardia
non specific ST changes
S1 Q3 T3 - seen in life threatening right ventricular strain, usually in near or total cardiovascular collapse

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13
Q

commonest ECG abnomality in PE

A

sinus tachy

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14
Q

CXR findings

A

also usually non specific
can rule out other causes eg. cardiac failure, pneumonia, pneumothorax
often appears normal
any abnormalities are subtle and usually only recognised in retrospect

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15
Q

CTPA

A

good sensitivity and specificity
available 24/7
may reveal other pathologies as well

cons:
- needs contrast which may be contraindicated
- often reveals irrelevant minor abnormalities
- sensitivity declines with time after event
- high radiation dose

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16
Q

V/Q scan

A

better to identify chronic CTEPH
low radiation dose - better for young patients and pregnant women

cons
- less sensitive
- very diifficult to interpret in presence of chronic heart/lung disease
- not available out of hours

17
Q

if the patient is in cardiovascular collapse

A

will be too unwell to move to radiology for a CTPA
bedside echocardiogram - will show acute right ventricular dilationand strain
may even see a clot extending into the right atrium

18
Q

treatment for the stable patient with first episode of VTE

A

oxygen to keep sats above 94%
subcut low molecular weight heparin - enoxaparin (clexane)
switch to oral anticoagulation for 3-6 monthss
- warfarin (titrate to INR 2-3)
- novel oral anticoagulatns such as Rivaroxaban

19
Q

follow up

A

3 months with repeat imaging
should have thrombophilia screen
overall 10% risk recurrance

20
Q

for the patients with 2nd episode of VTE

A

lifelong anticoagulation

21
Q

treatment of massive PE

A

need to be managed and resused on ICU
expensive thrombolysis with alteplase of tenecteplase
surgical pulmonary embolectomy - only available in tertiary centres of cardiothoracic surgery

22
Q

treatment for submassive PE

A

thrombolysis is very controversial
not currently recommended in guidelines
should be managed as a stable patient

23
Q

complications

A

sudden death
bleeding - from treatment
cardiac arrythmias - aF / tachyarrythmias
pleural effusion
peripheral PE: ppulmonary infarctions, ppulmonary infarcts can cavitate
chronic pulomonary embolism CTEPH

24
Q
A