Respiratory: pulmonary embolism

Question 1

When should PE be suspected?

Answer 1

Usually sudden onset symptoms:
* Dyspnoea - most common - present in 50% (acute severe in central PE, mild in small peripheral PE)
* Tachypnoea (present in 40%)
* Haemoptysis
* Pleuritic chest pain (present in 40%)
* Syncope/pre-syncope
* Features of DVT

Retrosternal chest pain (RV ischaemia)
Cough (23%)

But can be asymptomatic.

Question 2

What signs may be present in someone with PE?

Answer 2

• Elevated jugular venous pressure.
• Fever.
• Gallop rhythm, a wide split-second heart sound, tricuspid regurgitant murmur.
• Hypotension (systolic blood pressure less than 90 mmHg) and cardiogenic shock — haemodynamic instability is rare and indicates central and/or extensive PE with severely reduced haemodynamic reserve.
• Hypoxia.
• Pleural rub.
• Tachycardia (heart rate greater than 100 beats per minute).

Question 3

If low clinical suspicion use PERC score to decide if further investigation is needed. What is in the PERC score?

Answer 3

• Age >=50
• HR >=100
• Sats <95%
• Unilateral leg swelling
• Haemoptysis
• Recent surgery or trauma
• Prior PE or DVT
• Hormone use

If score 0 - no further work up needed as <2% chance of PE
If any are positive, PERC cannot be used to rule out PE

Question 4

When should suspected PE be urgently admitted?

Answer 4

• haemodynamic instability: SBP <90 or drop of 40 or more / unwell.
• pregnant or post-partum <6 weeks

Question 5

If not requiring emergency admission, use 2-level PE wells score to estimate clinical probablility of PE. What is in the Two-Level PE Wells Score?

Answer 5

• Clinical features of deep vein thrombosis (DVT; minimum of leg swelling and pain with palpation of the deep veins) 3
• An alternative diagnosis is less likely than PE 3
• Heart rate greater than 100 beats per minute 1.5
• Immobilization for more than 3 days or surgery in the previous 4 weeks 1.5
• Previous DVT or PE 1.5
• Haemoptysis 1
• Cancer (receiving treatment, treated in the last 6 months, or palliative) 1

Question 6

What should be done if Wells score >4 (PE likely)?

Answer 6

• hospital admission for urgent CTPA

Question 7

What should be done if Wells score 4 or less? (PE unlikely)

Answer 7

• Ddimer with result <4hrs. Interim anti-coagulation if result not within 4 hours (apixaban or rivaroxaban)
• if starting anti-coag , take baseline FBC, U&E, LFT, clotting - but do not wait for results. Review within 24hrs with results

Question 8

What should be done If D dimer positive in suspected PE?

Answer 8

• admit to hospital for urgent CTPA

Question 9

What should be done If D dimer negative in suspected PE?

Answer 9

Stop interim therapeutic anticoagulation (if appropriate).
Advise the person that it is not likely that they have a PE, but discuss the signs and symptoms, and when they should seek further medical help.

Question 10

After discharge on treatment for confirmed unprovoked PE, how should they be followed up in 1ry care?

Answer 10

• review medical Hx and baseline bloods
• offer physical exam if not known to have cancer
• only investigate further for cancer if they have any symptoms or signs
• if anticoags are planned to be stopped - test antiphospholipid abs, hereditary thrombophilia (if have 1st degree relative with DVT or PE)

Question 11

How long should anti-coagulation treatment continue for DVT or PE?

Answer 11

• at least 3 months (3-6 months for active cancer)
• consider stopping if provoking factor no longer present
• Consider continuing if unprovoked

Question 12

How should DOAC anticoagulants be monitored?

Answer 12

• baseline clotting, U&E, LFT, FBC
• Review after 1 month, then every 3 months - for adverse effects, adherence, BP.
• Repeat FBC, U&E, LFTs yearly (every 6 months if frail or >75)
• bloods more often in reduced CrCl (divide CrCl by 10 to get the monthly F/U)