Pulmonary Embolism (PE)

Question 1

Define Pulmonary Embolism (PE)

Answer 1

Occlusion within the pulmonary arteries, usually due to a blood clot but could also be fat, air and tumour

Question 2

Pulmonary embolism is when there is an occlusion within the pulmonary arteries.

What are the 4 possibilities that can occlude the arteries

Answer 2

Blood clot – usually breaks off and travels to the lungs

Fat

Air

Tumour

Question 3

Name some of the risk factors for pulmonary embolism (PE)

Answer 3

Deep vein thrombosis (DVT) – major risk factor

Previous VTE

Active cancer

Recent surgery (within 2-3 months)

Significant period of immobility e.g. hospitalisation

Pregnancy

Combined oral contraceptive pill

Question 4

What are patients given in hospital if they are deemed at risk of developing a DVT or PE

Answer 4

Given prophylactic treatment with low molecular weight heparin

Question 5

The development of VTE/PE is due to Virchow’s triad

What are the 3 components of this triad

Answer 5

• Virchow’s triad is three things that contribute to the development of the blood clots
  
  1. Venous stasis
  2. Endothelial injury
  3. Hypercoagulable state

Question 6

What are the classic triad of symptoms of pulmonary embolism (PE)

Answer 6

Pleuritic chest pain i.e. sharp pain on deep inspiration

Dyspnoea i.e. SoB

Haemoptysis

Question 7

Name the signs of right heart strain

Answer 7

Raised JVP

Hypotension

Tricuspid regurgitation

Loud P2 – split second heart sound as elevated pulmonary pressure leads to delay in pulmonary valve closure.

Question 8

What is the most common sign of pulmonary embolism (PE)

Answer 8

Tachypnoea - low respiratory rate

Question 9

What is the scoring tool used in determining the likelihood of pulmonary embolism (PE)

Answer 9

Wells score

Question 10

What is the Wells score that cause PE is likely

Answer 10

Score > 4

Question 11

What is the Wells score that cause PE is unlikely

Answer 11

Less than or equal to 4

Question 12

Name some of the components of the Wells Score for PE

Answer 12

An alternative diagnosis is less likely than PE

Heart rate > 100 beats per minute

Immobilisation for more than 3 days or surgery in the previous 4 weeks

Previous DVT/PE

Haemoptysis

Malignancy (on treatment, treated in the last 6 months, or palliative)

Question 13

If the Wells Score >4

What is the next step of investigating pulmonary embolism (PE)?

Answer 13

CT pulmonary angiogram (CTPA)

Question 14

If the Wells Score less than or equal to 4

What is the next step of investigating pulmonary embolism (PE)?

Answer 14

d-dimer

only if positive should a patient undergo CT pulmonary angiogram (CTPA)

Question 15

What is a d-dimer

Answer 15

D-dimer is a fibrin-degradation product, which is created when blood clots are broken down by the fibrinolytic system

Question 16

If Wells score suggests PE is unlikely (less than or equal to 4)

D-dimer positive.

What is the next investigation for pulmonary embolism (PE)?

Answer 16

CT pulmonary angiogram (CTPA)

Question 17

CT pulmonary angiogram (CTPA) is used in investigating pulmonary embolism (PE).

What is it and how does it help in investigating PE?

Answer 17

Chest CT scan with an IV contrast

Highlights the pulmonary arteries to demonstrate any blood clots

Question 18

Not every patient needs a d-dimer to diagnose pulmonary embolism (PE).

In what incidences is a d-dimer needed

Answer 18

Used before CT pulmonary angiogram (CTPA) in patients with a PE unlikely Wells score (< = 4)

Question 19

What should be started immediately even before the diagnosis of PE is confirmed in patients

Answer 19

Direct acting oral anticoagulants (DOACs) e.g. Apixaban, Rivaroxaban

Question 20

After initial management, anticoagulant therapy is required to continue for a period of time to prevent future DVT/PE.

What is the duration of this therapy?

Answer 20

3 months – for those with reversible cause

Beyond 3 months (typically 6 months) – if the cause is unclear, recurrent VTE, irreversible cause

3-6 months – active cancer

Question 21

After initial management, anticoagulant therapy is required to continue for a period of time to prevent future venous thromboembolism (VTE).

What is the duration of this therapy if there is a reversible cause of the VTE

Answer 21

3 months

Question 22

After initial management, anticoagulant therapy is required to continue for a period of time to prevent future venous thromboembolism (VTE).

What is the duration of this therapy if there is a cause is unclear, recurrent VTE, irreversible cause

Answer 22

Beyond 3 months (typically 6 months)

Question 23

After initial management, anticoagulant therapy is required to continue for a period of time to prevent future venous thromboembolism (VTE).

What is the duration of this therapy for those with active cancer

Answer 23

6 months

Question 24

When is thrombolysis the 1st line therapy for managing PE

Answer 24

Massive PE with haemodynamic compromise e.g hypotension

Question 25

What is a potential side effect of Thrombolysis

Answer 25

Significant risk of bleeding

Question 26

Thrombolysis is used to treat clots.

How does it work?

Answer 26

Involves injecting a fibrinolytic medication (they break down fibrin) that rapidly dissolves clots