Respiratory: Pneumothorax, PE & Pneumonia Flashcards
1
Q
What is a pneumothorax?
A
Air in pleural space - separating lung from chest wall
2
Q
What are the 2 major classifications of a pneumothorax?
A
Spontaneous & 2ary (to trauma, medical interventions i.e. iatrogenic, or lung pathology)
3
Q
Typical patient with a pneumothorax in exams?
A
A tall, thin, young man presenting with sudden breathlessness and pleuritic chest pain, possibly whilst playing sports.
4
Q
Causes of a pneumothorax?
A
- Spontaneous
- Trauma
- Iatrogenic, for example, due to lung biopsy, mechanical ventilation or central line insertion
- Lung pathologies such as infection, asthma or COPD
5
Q
Give some underlying pathologies that can lead to 2ary spontaneous pneumothorax’s
A
- Connective tissue disease e.g. Marfan’s syndrome, Ehlers-Danlos syndrome
- Obstructive lung disease e.g. asthma, COPD
- Infective lung disease e.g. TB, pneumonia
- Fibrotic lung disease e.g. cystic fibrosis, idiopathic pulmonary fibrosis
- Neoplastic disease e.g. bronchial carcinoma
6
Q
Traumatic pneumothorax’s can be classified into iatrogenic and non-iatrogenic causes.
Give some examples for both
A
Iatrogenic –> central line insertion, positive pressure ventilation, lung biopsy
Non-iatrogenic –> penetrating trauma, blunt trauma with rib fracture
7
Q
Give some symptoms of a pneumothorax
A
- Sudden onset SOB
- Pleuritic chest pain
8
Q
How is each factor affected in a pneumothorax:
a) Chest expansion
b) Percussion
c) Breath sounds
d) Vocal resonance
A
a) reduced on affected side
b) hyperresonant on affected side
c) reduced/absent on affected side with no added sounds
d) reduced on affected side
9
Q
What is the 1st line investigation in a pneumothorax?
A
CXR
10
Q
How is patient positioned in a CXR for a simple pneumothorax?
A
Erect (i.e. standing)
11
Q
CXR findings in a pneumothorax?
A
It shows an area between the lung tissue and the chest wall with no lung markings. There will be a line demarcating the edge of the lung where the lung markings end and the pneumothorax begins.
12
Q
How is a pneumothorax measured in size on a CXR?
A
Measuring horizontally from the lung edge to the inside of the chest wall at the level of the hilum (see zero to finals).
13
Q
What imaging can be used to detect a pneumothorax that is too small to be seen on a chest x-ray?
A
CT thorax
14
Q
What imaging can be used to measure the size of a pneumothorax ACCURATELY?
A
CT thorax
15
Q
Management of pneumothorax that is less than a 2cm rim of air on the CXR and there is no SOB?
A
No treatment is required as it will spontaneously resolve
Follow-up in 2 – 4 weeks is recommended
16
Q
Management of a pneumothorax that is more than a 2cm rim of air on the CXR and there is SOB?
A
Aspiration followed by reassessment
17
Q
If aspiration fails in a pneumothorax, what is the next step?
A
Chest drain
N.B. Unstable patients, bilateral or secondary pneumothoraces, generally require a chest drain.
18
Q
What type of cannula is used to aspirate a pneumothorax?
A
A 16-18G cannula under local anaesthetic
19
Q
Where is a chest drain located in a pneumothorax?
A
Triangle of safety
20
Q
What is the triangle of safety formed by (3 borders)?
A
1) 5th intercostal space (or inferior to nipple)
2) Midaxillary line (or lateral edge of latissimus dorsi)
3) Anterior axillary line (or lateral edge of pectoralis major)
See zero to finals for picture
21
Q
Is the needle inserted above or below the rib when inserting a chest drain in a pneumothorax?
A
The needle is inserted just above the rib to avoid the neurovascular bundle that runs just below the rib.
22
Q
Once the chest drain has been inserted in a pneumothorax, what should you do?
A
Get a CXR to check positioning
23
Q
How does a chest drain work in treating a pneumothorax?
A
1) The external end of the drain is placed underwater, creating a seal to prevent air from flowing back through the drain into the chest.
2) Air can exit the chest cavity and bubble through the water, but the water prevents air from re-entering the drain and chest.
3) During normal respiration, the water in the drain will rise and fall due to changes in pressure in the chest (described as “swinging”).
4) When the chest drain successfully treats the pneumothorax, air will bubble through the fluid in the drain bottle
24
Q
How to know when a chest drain has successfully treated a pneumothorax?
A
1) There will be swinging of the water with respiration
2) On a repeat CXR there will be reinflation of the lung
25
If a chest drain does not appear to have successfully treated a pneumothorax, what may be the problem?
1) Blocked or kinked tube
2) Incorrect position in the chest
3) Not correctly connected to the bottle
26
What are 2 key complications of chest drains?
1) Air leaks around the drain site (indicated by persistent bubbling of fluid, particularly on coughing)
2) Surgical emphysema (also known as subcutaneous emphysema) is when air collects in the subcutaneous tissue
27
What may indicate an air leak in a chest drain?
Persistent bubbling of fluid, particularly on coughing
28
What is a surgical/subcutaneous emphysema?
when air collects in the subcutaneous tissue
29
When may patients require SURGICAL interventions for a pneumothorax?
1) A chest drain fails to correct the pneumothorax
2) There is a persistent air leak in the drain
3) The pneumothorax reoccurs (recurrent pneumothorax)
30
What surgical method is used to correct a pneumothorax?
Video-assisted thoracoscopic surgery (VATS)
31
What are the 3 surgical options for pneumothorax?
1) Abrasive pleurodesis (using direct physical irritation of the pleura)
2) Chemical pleurodesis (using chemicals, such as talc powder, to irritate the pleura)
3) Pleurectomy (removal of the pleura)
32
What is pleurodesis?
Pleurodesis involves creating an inflammatory reaction in the pleural lining so the pleura STICKS together and the pleural space becomes SEALED.
This prevents further pneumothoraces from developing.
33
What is a tension pneumothorax?
Caused by trauma to the chest wall that creates a ONE-WAY valve that lets air IN but not OUT of the pleural space.
Therefore, with each breath, more air is drawn into the pleural space and cannot escape.
34
Why is tension pneumothorax an emergency condition?
It creates pressure inside the thorax to push the mediastinum across, kink the big vessels in the mediastinum and cause cardiorespiratory arrest.
35
Signs of a tension pneumothorax?
- Tracheal deviation away from the side of the pneumothorax
- Reduced air entry on the affected side
- Increased resonance to percussion on the affected side
- Tachycardia
- Hypotension
36
Management of a tension pneumothorax?
ABCDE approach
Insert a LARGE BORE cannula into the 2nd intercostal space in the midclavicular line (just above the third rib).
37
What is pneumonia?
Pneumonia is an infection of the lung tissue, causing inflammation in the alveolar space.
38
How is pneumonia seen on a CXR?
Consolidation
39
Define acute bronchitis
Acute bronchitis refers to infection and inflammation in the bronchi and bronchioles.
40
Is acute bronchitis a LRTI or URTI?
LRTI
41
Are LRTIs or URTIs more likely to be viral?
Upper respiratory tract infections (e.g., a common cold) are usually viral.
As a general rule, the lower down the respiratory tract, the higher the probability of bacterial infection, as opposed to viral.
42
What are the 4 classifications of pneumonia?
1) Community-acquired pneumonia (CAP)
2) Hospital-acquired pneumonia (HAP)
3) Ventilator-acquired pneumonia (VAP)
4) Aspiration pneumonia
43
When does HAP develop?
Develops after more than 48 hours in a hospital
44
Who does VAP develop in?
Develops in intubated patients in the intensive care unit
45
What is aspiration pneumonia?
Aspiration pneumonia is when the infection develops due to the aspiration of food or fluid
46
Who is aspiration pneumonia common in?
Impaired swallowing e.g. stroke, advanced dementia
47
What type of bacteria is aspiration pneumonia associated with?
Anaerobic bacteria
48
Symptoms of pneumonia?
- Cough
- Sputum production
- Shortness of breath
- Fever
- Feeling generally unwell
- Haemoptysis (coughing up blood)
- Pleuritic chest pain (sharp chest pain, worse on inspiration)
- Delirium (acute confusion)
49
Auscultation findings in pneumonia?
1) Bronchial breath sounds --> due to consolidation around the airways
2) Focal coarse crackles --> caused by air passing through sputum in the airways
50
Describe bronchial breath sounds
Harsh inspiratory and expiratory breath sound
51
Percussion findings in pneumonia?
Dullness --> due to lung tissue filled with sputum or collapsed
52
What signs may indicate SEPSIS 2ary to pneumonia?
- Tachycardia
- Tachypnoea
- Hypoxia (low oxygen)
- Hypotension (shock)
- Fever
- Confusion
53
When should the CRB-65 scoring system be used in pneumonia be used? When should CURB-65 be used?
CRB-65: out of hospital
CURB-65: in hospital
54
What CRB-65 score indicates the need to consider hospital assessment?
Score more than 0
55
Describe the CURB-65
Confusion
Urea >7 mmol/L
Respiratory rate >/= 30
BP <90 systolic or /= 65
56
What does a CURB-65 score of 0 or 1 indicate?
Consider treatment at home
57
What does a CURB-65 score of >/=2 indicate?
Consider hospital admission
58
What does a CURB-65 score of >/= 3 indicate?
Consider intensive care
59
What is the most common causative organism of pneumonia
Streptococcus pneumoniae (pneumococcus)
60
What organism typically causes pneumonia in COPD patients?
Haemophilus influenzae
61
Give some causes of typical pneumonia?
1) Strep. pneumoniae
2) Haemophilus influenzae
3) Moraxella catarrhalis
4) Pseudomonas aeruginosa
5) Staphylococcus aureus
6) Methicillin-resistant Staphylococcus aureus (MRSA)
7) Klebsiella pneumoniae
62
What is an atypical pneumonia?
Atypical pneumonia is caused by organisms that cannot be cultured in the normal way or detected using a gram stain.
63
What are the organisms causing atypical pneumonias?
1) Legionella pneumophila (Legionnaires’ disease)
2) Mycoplasma pneumoniae
3) Chlamydophila pneumoniae
4) Coxiella burnetii, or Q fever
5) Chlamydia psittaci
64
Which causative organism of pneumonia is particularly associated with high fever, rapid onset and herpes labialis?
Streptococcus pneumoniae (pneumococcus)
65
Which type of pneumonia often occurs in patients following influenza infection?
Staph. aureus
66
What 2 organisms typically cause pneumonia in cystic fibrosis patients?
1) Pseudomonas aeruginosa
2) Staphylococcus aureus
67
When does MRSA typically cause pneumonia?
In hospital-acquired infections
68
What organism typically causes pneumonia in immunocompromised patients or those with chronic pulmonary disease?
Moraxella catarrhalis
69
What organism typically causes pneumonia in patients with cystic fibrosis or bronchiectasis?
Pseudomonas aeruginosa
70
What is Legionella pneumophila typically caused by?
Typically caused by inhaling infected water from infected water systems, such as air conditioning units.
71
Which type of pneumonia causes hyponatraemia? Why?
Legionella pneumophilia - can cause a syndrome of inappropriate ADH (SIADH), resulting in hyponatraemia
72
Typical patient with Legionella pneumophila?
The typical exam patient has recently had a cheap hotel holiday and presents with pneumonia symptoms and hyponatraemia.
73
Initial screening test for Legionella pneumophila (Legionnaires’ disease)?
A urine antigen test
74
What type of pneumonia can cause SIADH?
Legionella pneumophila (Legionnaires’ disease)
75
Which organism can cause erythema multiforme?
Mycoplasma pneumoniae
76
What is erythema multiforme?
Rash characterised by varying-sized “target lesions” formed by pink rings with pale centres
77
What type of severity of pneumonia does Mycoplasma pneumoniae cause?
Milder pneumonia
78
What type of pneumonia can cause neurological symptoms in young patients?
Mycoplasma pneumoniae
79
What type of pneumonia often present a dry cough and atypical chest signs/x-ray findings. Autoimmune haemolytic anaemia and erythema multiforme may be seen?
Mycoplasma pneumoniae
80
What type of pneumonia can cause autoimmune haemolytic anaemia?
Mycoplasma pneumoniae
81
What type of pneumonia causes mild to moderate chronic pneumonia and wheezing in school-age children?
Chlamydophila pneumoniae
Be cautious, as this presentation is common without chlamydophila pneumoniae infection.
82
What type of pneumonia is linked to exposure to the bodily fluids of animals?
Coxiella burnetii, or Q fever
The typical exam patient is a farmer with a flu-like illness.
83
What type of pneumonia is typically contracted from contact with infected birds?
Chlamydia psittaci
The typical exam patient is a parrot owner.
84
Pneumonic for remembering the 5 causes of atypical pneumonia:
“Legions of psittaci MCQs”
Legions – Legionella pneumophila
Psittaci – Chlamydia psittaci
M – Mycoplasma pneumoniae
C – Chlamydophila pneumoniae
Qs – Q fever (coxiella burnetii)
85
What type of pneumonia is classically seen in alcoholics or diabetes?
Klebsiella pneumoniae
86
What is Pneumocystis jirovecii pneumonia (PCP)?
a fungal pneumonia
87
Who does Pneumocystis jirovecii pneumonia typically occur in?
Immunocompromised patients e.g. poorly controlled HIV
88
How does Pneumocystis jirovecii pneumonia typically present?
- Dry cough
- SOB on exertion (and exercise-induced desaturations)
- Night sweats
- Absence of chest signs
89
What is the treatment for Pneumocystis jirovecii pneumonia?
Co-trimoxazole (trimethoprim/sulfamethoxazole) i.e. Septrin
Patients with a low CD4 count are prescribed prophylactic co-trimoxazole to protect against PCP.
90
The covid-19 virus (SARS-CoV-2) can cause pneumonia.
Symptoms?
- Anosmia (loss of smell)
- Patients may not feel particularly short of breath despite having low oxygen saturations (“silent hypoxia”)
91
Management of COVID-19 pneumonia?
Respiratory support (e.g., oxygen), dexamethasone and monoclonal antibodies.
92
What is idiopathic interstitial pneumonia?
Idiopathic interstitial pneumonia is a group of non-infective causes of pneumonia.
E.g. cryptogenic organizing pneumonia --> a form of bronchiolitis that may develop as a complication of rheumatoid arthritis or amiodarone therapy
93
Classical CXR finding in pneumonia?
Consolidation
94
Investigations in pneumonia for patients admitted to hospital?
Patients in the community with CRB 0 or 1 pneumonia do not necessarily need investigations.
- CXR
- FBC
- Renal profile i.e. U&Es
- CRP (raised)
- ABG (if low O2 sats or patient has pre-existing respiratory disease e.g. COPD)
Patients with moderate or severe infection will also have:
1) Sputum cultures
2) Blood cultures
3) Pneumococcal and Legionella urinary antigen tests
95
FBC in bacterial pneumonia?
Neutrophilia (raised WCC)
96
How can WCC and CRP indicate severity of infection?
White blood cells and CRP are raised roughly in proportion to the severity of the infection.
97
When does CRP rise in relation to WCC?
CRP starts rising 6 hours behind the onset of inflammation and peaks after 24-48 hours. It may initially be low before becoming very high a day or two later.
98
When does CRP peak?
After 24-48 hours
99
Management of pneumonia?
1) Antibiotics (follow local guidelines)
2) Supportive care
100
1st line Abx in the management of low-severity community-acquired pneumonia?
Typical pneumonia --> amoxicillin
Atypical --> macrolides (e.g. clarithromycin), fluoroquinolones (e.g. levofloxacin), and tetracyclines (e.g. doxycycline)
Typically treated with 5 day course of Abx
101
If patient is pencillin allergic, what Abx can be given in pneumonia?
macrolide (e.g. clarithromycin) or tetracycline (e.g. doxycycline)
102
Management of moderate and high-severity community acquired pneumonia?
- DUAL Abx therapy is recommended with amoxicillin and a macrolide e.g. co-amoxiclav + clarithromycin
- A 7-10 day course is recommended
- Usually treated initially with intravenous antibiotics and stepped down to oral antibiotics as the condition improves
- Respiratory support (e.g., oxygen or intubation and ventilation)
103
When should all cases of pneumonia have a repeat CXR?
6 weeks after clinical resolution to ensure that the consolidatoin has resolves and there is no underlying secondary abnormalities (e.g. a lung tumour).
104
Complications of pneumonia?
Sepsis
Acute respiratory distress syndrome
Pleural effusion
Empyema
Lung abscess
Death
105
Pathophysiology of pneumonia?
1. Inflammation leads to fluid and blood cells leaking into the alveoli.
2. The infection spreads across the alveoli and eventually the lung tissue becomes consolidated, impairing the gas exchange due to reduced ventilation.
106
what is a pleural rub? cause?
An audible sound heard in patients with pleurisy
Caused by layers of pleura rubbing against each other
107
Why is a urine sample for antigen testing required in pneumonia?
To distinguish between legionella and pneumococcal urinary antigens
108
After how many days of starting Abx should inflammatory markers be repeated in pneumonia?
3 days
109
Top 3 causative organisms of hospital acquired pneumonia?
1) Pseudomonas aeruginosa
2) Staph. aureus
3) Enterobacteria
110
Risk factors for aspiration pneumonia?
- Myasthenia gravis
- Bulbar palsy
- Alcoholism
- Achalasia
- Poor dental hygiene
111
Which lung is more affected in aspiration pneumonia? Why?
R lung more affected due to R bronchus being more vertical and wider
112
What patient is chlamydophila pnuemoniae typically seen in?
School aged child with mild to moderate chronic pneumonia and wheeze
113
What is a pulmonary embolism (PE)?
A blood clot (thrombus) in the pulmonary arteries.
The thrombus will block the blood flow to the lung tissue and strain the right side of the heart. DVTs and PEs are collectively known as venous thromboembolism (VTE).
114
What is an embolus?
An embolus is a thrombus that has travelled in the blood, often from a deep vein thrombosis (DVT) in a leg.
115
Risk factors for PE?
- Immobility
- Recent surgery
- Recent long-haul travel
- Hormone therapy with oestrogen (e.g. COCP, HRT)
- Malignancy
- Pregnancy
- Polycythaemia (raised haemoglobin)
- Systemic lupus erythematosus
- Thrombophilia
In your exams, when a patient presents with possible features of a DVT or PE, ask about risk factors such as periods of immobility, surgery and long-haul flights to score extra points.
116
How is the risk of VTE reduced in patients undergoing surgery?
prophylactic treatment
117
Every patient admitted to hospital is assessed for their risk of venous thromboembolism (VTE).
What is the prophylaxis for higher-risk patients?
1) Low molecular weight heparin (e.g., enoxaparin) unless contraindicated
2) Anti-embolic compression stockings unless contraindicated
118
Contraindications for VTE prophylaxis (heparin)?
- Active bleeding
- Existing anticoagulations e.g. warfarin, DOAC
119
Contraindication for anti-embolic compression stockings?
Peripheral arterial disease (PAD)
120
Presentation of a PE?
- Can be asymptomatic and discovered incidentally (present with subtle signs and symptoms, or even cause sudden death)
- SOB
- Cough
- Haemoptysis (coughing up blood)
- Pleuritic chest pain (sharp pain on inspiration)
- Hypoxia
- Tachycardia
- Raised respiratory rate
- Low-grade fever
- Haemodynamic instability causing hypotension
There may also be signs and symptoms of a deep vein thrombosis, such as unilateral leg swelling and tenderness.
121
Typical triad of symptoms in PE?
1) Pleuritic chest pain
2) Haemoptysis
3) Dyspnoea
However, few patients (10%) present this way - often difficult to diagnose
122
4 most common clinical signs in PE?
1) Tachypnea (respiratory rate >16/min) - 96%
2) Crackles - 58%
3) Tachycardia (heart rate >100/min) - 44%
4) Fever (temperature >37.8°C) - 43%
It is interesting to note that the Well's criteria for diagnosing a PE use tachycardia rather than tachypnoea.
123
What is the pulmonary embolism rule-out criteria (PERC)?
When is it used?
The pulmonary embolism rule-out criteria (PERC) are recommended by the NICE when the clinician estimates LESS THAN A 15% probability of a PE to decide whether further investigations for a PE are needed.
If all the criteria are met, further investigations for a PE are NOT required.
124
If all criteria of the PERC are met, what happens?
If ALL the criteria are met (i.e. absent), further investigations for a PE are NOT required.
125
When should PERC be used?
This should be done when you think there is a low pre-test probability of PE (<15%) , but want more reassurance that it isn't the diagnosis
126
What are the PERC?
1) Age >/= 50
2) Heart rate >/= 100
3) O2 sats (
127
When should a Wells score be performed?
If a PE IS suspected (instead of PERC)
128
What Wells score indicates a PE is likely?
>4
129
What Wells score indicates a PE is unlikely?
4 or less
130
If the Wells score is >4 (PE is likely), what is the next step?
Perform a CT pulmonary angiogram (CTPA) or alternative imaging
If positive --> PE diagnosed
If negative --> consider proximal leg US if DVT suspected
131
Why should a CXR be performed in PE?
A chest x-ray is usually normal in a pulmonary embolism but is required to rule out other pathology.
132
What are the three imaging options for establishing a diagnosis of a pulmonary embolism?
1) CT pulmonary angiogram --> the usual first-line
2) Ventilation-perfusion single photon emission computed tomography (V/Q SPECT) scan
3) Planar ventilation–perfusion (VQ) scan
133
If the Wells score is
Perform a d-dimer (with result within 4 hours)
134
If the d-dimer result is positive in a PE, what is the next step?
Perform a CTPA
If positive --> PE diagnosed
If negative --> consider proximal leg US if DVT suspected
135
What is a d-dimer test?
D-dimer is a sensitive (95%) but not a specific blood test for VTE.
It helps exclude VTE where there is a low suspicion. It is almost always raised if there is a DVT.
136
What other conditions can cause a raised d-dimer?
Pneumonia
Malignancy
Heart failure
Surgery
Pregnancy
137
If d-dimer is negative in suspcted PE, what is next step?
Consider alternative diagnosis and stop anticoagulation
138
What is a CT pulmonary angiogram (CTPA)?
A chest CT scan with an IV contrast that highlights the pulmonary arteries to demonstrate any blood clots.
139
1st line imaging in PE? Why?
CTPA
This is readily available, provides a more definitive assessment and gives information about alternative diagnoses, such as pneumonia or malignancy.
140
What is a ventilation-perfusion (VQ) scan?
Involves using radioactive isotopes and a gamma camera to compare ventilation with the perfusion of the lung.
141
When would a VQ scan be indicated over a CTPA in a PE?
1) renal impairment (due to contrast in CTPA)
2) contrast allergy
3) risk from radiation
142
How does a VQ scan work in PE?
1) First, the isotopes are inhaled to fill the lungs, and a picture is taken to demonstrate ventilation.
2) Next, a contrast containing isotopes is injected, and a picture is taken to illustrate perfusion.
3) The two images are compared.
143
VQ scan in PE?
With a PE, there will be a deficit in PERFUSION as the thrombus blocks blood flow to the lung tissue. The lung tissue will be VENTILATED but not PERFUSED. Planar V/Q scans produce 2D images. V/Q SPECT scans produce 3D images, making them more accurate.
144
ABG results in a PE?
respiratory alkalosis as hypoxia causes a raised RR
145
Management of a PE?
1) Suppirtive maangement (e.g. admission to hospital as required, O2 & analgesia as required)
2) Anticoagulation
146
1st line anticoagulation in PE?
DOACs (Apixaban or rivaroxaban)
(LMWH is the main alternative)
147
When should anticoagulation be started in suspected PE patients?
This should be started immediately in patients where PE is suspected and there is a delay in getting a scan to confirm the diagnosis.
148
Management of a massive PE with haemodynamic compromise?
Continuous infusion of unfractionated heparin and considering thrombolysis.
149
What is thrombolysis?
Thrombolysis involves injecting a fibrinolytic (breaks down fibrin) medication that rapidly dissolves clots.
150
Why is thrombolysis only used in patients with a massive PE ?
Due to dangers --> significant risk of bleeding with thrombolysis
151
Examples of thrombolytic agents?
1) Streptokinase
2) Alteplase
3) Tenecteplase
152
What are the 2 ways that thrombolysis can be performed?
1) Intravenously using a peripheral cannula
2) Catheter-directed thrombolysis (directly into the pulmonary arteries using a central catheter)
152
What are the 3 options of long-term anticoagulation in VTE?
1) DOAC
2) Warfarin
3) LMWH
153
Examples of DOACs?
apixaban, rivaroxaban, edoxaban and dabigatran
154
If patient has active cancer, what is 1st line anticoagulation in PE?
DOAC (unless contraindication)
155
How long should patients with a PE have anticoagulation for?
At least 3 months
156
What determines whether anticoagulation is carried on longer than 3 months in a PE?
whether the VTE was provoked or unprovoked
(if unprovoked, requires longer anticoagulation)
157
What is a provoked VTE?
Due to an obvious precipitating event e.g. immobilisation following major surgery
158
What is an unprovoked VTE?
Occurs in the absence of an obvious precipitating event, i.e. there is a possibility that there are unknown factors (e.g. mild thrombophilia) making the patient more at risk from further clots
159
When is anticoagultion stopped after a provoked VTE?
What is the exception to this?
Typically stopped after the initial 3 months (3 to 6 months for people with active cancer)
160
When is anticoagultion stopped after an unprovoked VTE?
treatment is typically continued for up to 3 further months (i.e. 6 months in total)
161
Contraindications to DOACs?
1) Severe renal impairment (creatinine clearance less than 15 ml/min)
2) Antiphospholipid syndrome
3) Pregnancy
162
1st line anticoagulant in PE in pregnancy?
LMWH
163
Length of anticoagulation following a PE in patients with active cancer?
3-6 months
164
Mechanism of warfarin?
Vitamin K antagonist --> reduces synthesis of active clotting factors
165
How are warfarin levels monitored?
The international normalised ratio (INR) blood test --> tells you how long it takes for your blood to clot.
166
Target INR in people taking warfarin when treating DVTs and PEs?
Between 2 and 3
167
1st line anticoagulation in patients with antiphospholipid syndrome?
Warfarin (also require initial concurrent treatment with LMWH)
168
Classic ECG changes in PE?
1) Large S waves in lead I
2) Large Q waves in lead III
3) Inverted T wave in lead III (only seen in 20% of patients)
4) Can see right bundle branch block and right axis deviation
5) Can see sinus tachycardia
169
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