syncope, PE, AMS Flashcards
medications that can prolong the QT interval
erythromycin, clarithromycin, haloperidol, amiodarone, droperidol, and others
in the evaluation of syncope, ?are the only level A recommendations from the American College of Emergency Physicians (ACEP)
a good thorough history, a physical examination, and ECG
The San Francisco Syncope rule uses five criteria to predict who requires hospitalization
history of CHF, abnormal ECG, hematocrit less than 30, shortness of breath, and/or systolic BP of less than 90 mm Hg at triage
The OESIL score is based upon
abnormal ECG, history of cardiac disease, age less than 65, and syncope without prodrome
The ROSE predictors are:
BNP +300, positive fecal occult blood, hemoglobin less than 9.0, oxygen saturation less than 94%, and Q waves present on ECG
V/Q scans to dx PEs are used in ?
renal failure and pregnant pts (actually Q without the P in preggos)
gold standard of PE dx
CTPA: CT pulmonary angiography
even better: MDCTA (high resolution)
used to be pulmonary angiography, but more invasive and higher M/M
The Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II) study
if low pretest probability of DVT
get US
if normal, DVT r/o
if abnormal, tx DVT
if medium pretest probability of DVT
get US
if abnormal, tx DVT
if normal, get D dimer
if D dimer is negative, DVT r/o
if D dimer positive, tx DVT
if no D dimer available, US in 1 week
if high pretest probability of DVT
get US if abnormal, tx DVT if normal, get venography if abnormal, tx DVT if normal, DVT r/o
“gold standard” for DVT dx
Venography
However, due to its invasiveness, risk of reaction to contrast dye, and the advent of newer technologies that are just as accurate, venography is rarely used in clinical practice
All patients diagnosed with a DVT where? should be treated with anticoagulation
which anticoagulants for DVT/PE?
at or above the popliteal level
UFH
LMWH: enoxaparin (Lovenox), dalteparin, fondaparinux
long term: warfarin
PE s/s
sudden onset cough (3%-55%) blood-streaked sputum (3%-40%) sudden onset of dyspnea at rest or with exertion (75%) splinting of ribs with breathing chest pain (50%-85%) diaphoresis (25%-40%) Nonspecific signs of PE include *tachypnea (50%-60%) tachycardia (25%-70%) rales/crackles (50%) low-grade fever (7%-50%)
Unusual clinical presentations of PE
seizure, syncope, abdominal pain, high fever, productive cough, adult-onset asthma, new-onset supraventricular arrhythmias, or hiccups
Wells Criteria for pretest probability of PE
Suspected DVT- 3
An alternate diagnosis is less likely than PE- 3
HR +100 bpm- 1.5
Immobilization or surgery in the previous 4 weeks- 1.5
Previous DVT/PE- 1.5
Hemoptysis- 1
Malignancy (being treated currently or in the last 6 months)- 1
Scoring of Wells Criteria
0-2: 4% LOW
3-6: 21% MODERATE
6+: 67% HIGH RISK
PERC Rule Criteria
if 8 present, very low likely PE (used if low PTP)
Age less than 50 years Pulse less than 100 bpm SaO2 +94% No unilateral leg swelling No hemoptysis No recent trauma or surgery No prior PE or DVT No hormone use
initial CXR in PE
abnormal in 76% to 90% of patients no diagnostic findings, few rare classic signs: Westermark sign (peripheral lung vasoconstriction) and Hampton hump (pleural wedge-shaped density associated with pulmonary infarction)
CXR progression in PE
suggestive of atelectasis, pleural effusion, and elevated hemidiaphragm. After 2 to 3 days, the CXR in one-third of patients with PE demonstrates focal infiltrates mimicking pneumonia
but VARIABLE, so limited use
4 groups of V/Q scan
normal, low probability, indeterminant, and high probability
ABGs are commonly done in suspected PE but limited how?
normal PaO2, normal PCO2, and normal A-a oxygen gradient does not exclude the diagnosis of PE
Thrombolytic therapy in PE?
advocated for those individuals with a massive PE, such as those with hypotension for whom mortality is as high as 20% to 30%.
There are no conclusive studies that prove a survival advantage for thrombolytic therapy in PE
80% of PEs develop from DVTs involving what veins?
the iliac, femoral, or popliteal veins
Healthy patients without any use of antimicrobials in the past 3 months with presumed CAP are best treated with ?
a macrolide (azithromycin)
