Pulmonary Embolism (Venous thromboembolic disease) (VTE)

Question 1

what is Pulmonary embolism (PE)?

Answer 1

Obstruction of the pulmonary artery or one of its branches travels from elsewhere in the body

Question 2

What are the components of the Virchow’s triad?

Answer 2

1. Alterations in blood flow (ie. stasis)
2. Vascular endothelial injury
3. Alterations in the constituents of the blood

Question 3

Differentiate Acute PE, Subacute PE and Chronic PE

Answer 3

Acute - signs and symptoms develop immediately after obstruction of pulmonary vessels prompting evaluation
Subacute - symptoms have been ongoing. patients presents days or weeks following initial event
Chronic - Multiple small PEs, indolent symptoms, slowly develop symptoms of pulmonary hypertension over many years

Question 4

What are the three vital sign findings in acute PE?

Answer 4

Tachypnea, tachycardia, hypoxia

Question 5

What is the most common EKG finding in acute PE?

Answer 5

Sinus tachycardia

Question 6

what at the 3 locations of Pulmonary Embolism?

Answer 6

• Saddle (3-6%)
• Segmental
• Subsegmental

Question 7

What are the risk factors for PE (name 4)

Answer 7

• Sedentary state (Hospitalized/bedrest, Prolonged travel, lifestyle )
• Malignancy
• Hx VTE in the past
• Pregnancy
• Oral Contraceptives
• Obesity
• Heavy cigarette smoking (>25 cigarettes per day)
• Hypertension
• Inherited hypercoagulable disorder

Question 8

Name 3 Symptoms of Pulmonary Embolism

Answer 8

• Sudden shortness of breath
• Pleuritic chest discomfort
• Heart palpitations

Question 9

What is a D-Dimer and who should get a D-Dimer test?

Answer 9

• Degradation product of cross-linked fibrin
• Only use D-Dimer testing in low probability patients when ruling out DVT and low to mod probability when ruling out PE.
• Don’t measure D-Dimer at all on super duper uber low low prob patients

Question 10

What is the PERC Rule (Pulmonary Embolism Rule out Criteria)?

Answer 10

Designed to identify patients with a low clinical probability of pE in whom the risk of unnecessary testing outweighs the risk of PE.

Question 11

Which Imaging modality is usually the best choice for diagnosing acute PE?

Answer 11

-Chest CTA (with contrast)

Question 12

Who should get a VQ scan instead of CTA?

Answer 12

1. Allergic to contrast dye
2. Contraindication to contrast dye
   a. Pregnancy
   b. renal failure

Question 13

Who should be considered for thrombolysis (tPA) for acute PE?

Answer 13

clot dissolution with thrombolysis (tPA)
Reserved for high risk of adverse clinical outcome (hemodynamically unstable, likely poor survival without aggressive treatment)
-Hemodynamic instability
-RV dysfunction (hypokinesis)
-RV enlargement
-Elevated Troponin

Question 14

What are the features of right heart strain on EKG? (name 3)

Answer 14

1. Deep T wave inversions in anterior leads and inferior leads
2. Incomplete or complete RBBB
3. S1Q3T3 pattern

Question 15

What is the standard treatment of acute pulmonary embolism?

Answer 15

Anticoagulation, and should start immediately

Question 16

What are the Indications for IVC filters?

Answer 16

• Active bleeding precludes anticoagulation
• Recurrent venous thrombosis despite intensive anticoagulation
• High risk patients who are not candidates for fibrinolysis