Resp - Pulmonary Embolism

Question 1

Causes

Answer 1

• Usually DVTs in proximal leg or iliac veins

- Rarely: RV embolism post MI or septic emboli in right sided endocarditis

Question 2

Risk factors: SPASMODICAL

Answer 2

• Sex: female
• pregnant
• Age
• surgery: classically 10d post op during valsava
• malignancy
• oestrogen: OCP/HRT
• immobility
• colossal size
• lupus

Question 3

Symptoms

Answer 3

• dyspnea
• pleuritic chest main
• Haemoptysis
• syncope
• CVS collapse
• 60-80% of pts who die had 0 symptoms - usually find smaller events before killer PE, in post-mortem

Question 4

Signs

Answer 4

• fever
• cyanosis
• tachycardia/tachypnea
• RHF: hypotension, raised JVP, loud P2 heart sound
• evidence of cause: DVT

Question 5

Ix

Answer 5

• Bloods: FBC, U+E, clotting, D-dimer (used to rule out a PE if negative and have low clinical suspicion)
• ABG: can be normal or low PaO2/PaCO2 and high pH
• CXR: normal or oligaemia (absence of lung markets b/c reduction in local perfusion) or linear atelectasis (localised area of lung collapse)
• ECG: sinus tachy
• Dopple: thigh and pelvis (+ve in 60%)
• CTPA: v good sensitivity
• V/Q: use if pt is pregnant

Question 6

How to establish a diagnosis

Answer 6

1. Use Well’s score: 1-3
2. If low probability: perform D-Dimer
   - Negative: exclude PE
   - Positive: CTPA
3. If high probability from Well’s (2-3) then do CTPA right away

Question 7

Causes of raised D Dimer

Answer 7

• Venous thromboembolic disease
• increasing age
• Cancer
• infection
• post surgery
• haematoma
• peripheral vascular disease
• liver disease
• inflammation
• pregnancy

Question 8

Prevention for pt while in hospital

Answer 8

• Risk assess all pts
• TEDS
• Prophylactive LMWH
• Avoid OCP/HRT if at risk

Question 9

On going Mx post event

Answer 9

• TEDS whilst in hospital
• Continue LMWH until IRN >2 (at least 5d) then switch to warfarin
• Duration of Rx: remedial cause (3/12), no identifiable cause (6/12), ongoing cause OR 2nd event (indefinite)

Question 10

Outline the acute Mx of a patient with a PE

Answer 10

• Sit up + 100% O2 via NRB mask
• Analgesia: morphine +/- metoclopramide if distressed
• If pt is critically ill and is presenting with massive CVS collapse: consider thrombolysis: Alteplase 50mg bolus
• LMWH: enoxaparin 1.5mg/kg/24h SC
• Call for help