Pulmonary Embolus

Question 1

What are the main causes of pulmonary embolus?

Answer 1

Majority: DVT in proximal leg or iliac veins

Rarely:

• Right ventricle post-MI
• Septic emboli in right-sided endocarditis

Question 2

What are the risk factors associated with pulmonary embolus?

Answer 2

SPASMODICAL

Sex: F
Pregnancy
Age (increasing)
Surgery
Malignancy
Oestrogen (OCP/HRT)
DVT/previous PE
Immobility (bed-bound, long haul flight)
Colossal size
Antiphospholipid antibodies
Lupus anticoagulant

Question 3

What symptoms might a patient with a pulmonary embolism present with?

Answer 3

Dyspnoea
Pleuritic pain
Haemoptysis
Syncope

Question 4

What signs might you find on examination of a patient with pulmonary embolism?

Answer 4

Fever
Cyanosis
Tachycardia
Tachypnoea
RHF: hypotension, raised JVP
Signs of DVT (evidence of cause)

Question 5

How would you investigate a ?pulmonary embolus?

Answer 5

Bloods: FBC, UEs, clotting, D-dimer

ABG: normal or ↓PaO2 and ↓PaCO2, ↑pH

CXR: normal or oligaemia, linear atelectasis

ECG: sinus tachycardia, RBBB, right ventricular strain
(inverted T in V1-V4)

Doppler US: thigh and pelvis (+ve in 60%)

CTPA + venous phase of legs and pelvis

Question 6

What score helps a clinician decide the likelihood of a VTE?

Answer 6

Well’s score

• Low Wells = perform D-Dimer to decide whether or not CTPA is required.
• High Wells = sttraight to CTPA

NOTE: -ve D-dimer has a 95% NPV for PE.

Question 7

How would you manage an acute PE?

Answer 7

O2

• sit patient up
• 100 O2via non-rebreather

Analgesia

Thrombolysis/embolectomy

LMW Heparin

Maintain BP, TEDS, consider VC filter for repeat DVT/PE