pulmonary vascular disease

Question 1

where do the majority of PE arise from?

Answer 1

propagation of lower limb DVT

Question 2

what are the rare causes of PE?

Answer 2

septic emboli

tumour

fat

air

amniotic fluid

placenta

Question 3

what are the investigations for VTE?

Answer 3

chest radiograpyhy

ECG to exclude differential diagnosis such as acute MI and pericarditis

arterial blood gases

imaging: CT pulmonary angiography

Question 4

what should raise suspicion of PE?

Answer 4

acutely breathless and hypoxaemic patient

bilateral changes in patient presenting with unilateral pleuritic chest pain

Question 5

what is the management of PE/ VTE?

Answer 5

oxygen given to all hypoxaemic patients

circulatory shock treated with IV fluids or plasma expander

anticoagulation: commenced immediately in patients with high/ intermediate probability - heparin

persisitent prothrombotic risk- anticoagulated for life

thrombolytic therapy: presenting with acute massive PE accompanied by cardiogenic shock

Question 6

what is the algorithm for the investigation of patients with suspected pulmonary thromboembolism?

Answer 6

assess clinical risk and measure D dimer levels

if D- dimer negative, risk is high, ultrasound leg veins with CT pulmonary aniogram or V/Q scan , D dimer negative risk low then not DVT/PE

if D dimer positive, risk high then treat and then confirm diagnosis, risk low then do the scans

Question 7

what are the risk factors for venous thromboembolism?

Answer 7

surgery

obstetrics

cardiorespiratory disease

lower limb problems

malignant disease

other: increasing age, trauma

Question 8

what are the features of pulmonary thromboembolism on x ray?

Answer 8

pulmonary opacities

wedge-shaped opacity

horizonal linear opacities

pleural effusions

oligaemia of lung field

elevated hemidiaphragm

enlarged pulmonary artery

Question 9

what are the features of acute massive PE?

pathophysiology, symptoms, signs, chest x-ray, ECG, arterial blood gases, alternative diagnoses

Answer 9

patho: major haemodynamic effects- reduced cardiac output, acute right heart failure
symptoms: faintness or collapse, crushing central chest pain, apprehension, severe dyspnoea
signs: major circulatory collapse- tachycardia, hypotension, Increased JVP, right ventricular gallop rhythm, loud p2, severe cyanosis, decreased urinary output

chest x-ray: usually normal, may be subtle oligaemia

ECG: RBBB, anterior T wave inversion

arterial blood gas: decreased oxygen and co2, metabolic acidosis

alternative diagnoses: MI, pericardial tamponade, aortic dissection

Question 10

what are the features of acute small/medium PE?

pathophysiology, symptoms, signs, chest x-ray, ECG, arterial blood gases, alternative diagnoses

Answer 10

patho: occlusion of segmental pulmonary artery: infarction with or without effusoin
symptoms: pleuritic chest pain, restricted breathing haemoptysis
signs: tachycardia, pleural rub, raised hemidiaphragm, crackles, effusion (often blood stained), low - grade fever

chest xray: pleuropulmonary opacities, pleural effusion, linear shadows, raised hemidiaphragm

ECG: sinus tachycardia

arterial blood gases: may be normal or decreased oxygen and co2

alternative diagnoses: pneumonia, pneumothorax, musculoskeletal chest pain