Respiratory - Pulmonary Embolism

Question 1

What are the most common symptoms seen in PE?

Answer 1

chest pain - typically pleuritic
dyspnoea
haemoptysis
tachycardia
tachypnoea

Question 2

If you have a low suspicion of PE and would want to rule it out, which criteria could you use?

Answer 2

Pulmonary embolism rule out criteria (PERC)
* Used when there is a <15% probability of PE (can be difficult to quantify)
* all the criteria must be absent to have negative PERC result, i.e. rule-out PE
* a negative PERC reduces the probability of PE to < 2%

Question 3

If you have a high clinical suspicion of a PE, what score should be used to guide your further managment? How would you interpret it?

Answer 3

2-Level Wells score.
PE Unlikly - 4 points or less
PE likely - more than 4 points

Question 4

A 55 year old female patient has dsypnoea and pleuritic chest pain. They have unilateral leg swelling that is painful on palpation. They have just arrived back into the UK from Australia via a direct flight.
PMH - Nil

Observations
HR - 112
SATs - 93% on 2L
BP - 115/79
RR - 28
Temp - 37.2

How should this patient be managed?

Answer 4

Wells score = 4.5
Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins)
Heart rate > 100 beats per minute

A - E approach
Bloods - ABG, FBC, Us & Es, LFTs, Clotting studies, maybe cardiac markers.
CXR
ECG
Immediate CTPA

If there is a delay in performing a CTPA then start the patient on a DOAC in the interim.

Question 5

If a patient with suspected PE has a Wells score of 3, how would you manage the patient?

Answer 5

Arrange a D-dimer test. If positive then perform a CTPA. If negative then consider another diagnosis.

Question 6

What is the most common ECG changes seen in PE?

Answer 6

Sinus tachycardia

Question 7

What are the ‘classic’ ECG changes seen in PE?

Answer 7

• a large S wave in lead I
• A large Q wave in lead III
• Inverted T wave in lead III
• S1 Q3 T3
• An example is shown below