Thromboembolic disease: PE (R1) Flashcards

1
Q

Pathophysiology of PE?

A
  • Usually arises from embolisation of DVT
  • Blockage in the pulmonary arteries –> capillaries
  • Impaired gas exchange leads to hypoxia and hypercapnia. This stimulates drive to breathe (SOB)
  • Also leads to pulmonary infarction
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2
Q

Complications
- 3 acute complications?
- Is there a high risk of recurrence?

A

Shock: less blood reaches left ventricle –> reduced CO
Acute cor pulmonale: increased resistance in pulmonary arteries …
Death

Yes, there is a high risk of recurrence.

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3
Q

History:
- Symptoms of PE?

A

Pleuritic chest pain
SOB (may only be exertional!)
Cough +- haemoptysis
Palpitations
Syncope/fainting

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4
Q

Exam
- Vitals?
- Importance of taking exertional vitals in PE?
- Are there additional exam findings in your notes?

A

↑HR, ↑ RR, ↓BP, ↓ PO2
Potentially ↑ temperature - if infection related

Yes - some people may only show vitals on exertion

Yes

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5
Q

Investigations
- Bedside: supportive test?

A

ECG

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6
Q

Investigations
- Bedside: ECG
What may it show?

A
  • Most common: sinus tachycardia
  • May be normal
  • Signs of right heart strain
  • S1 Q3 T3 (uncommon):
    • S1: deep S waves in lead I
    • Q3: deep Q waves in lead III
    • T3: T wave inversion in lead III
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7
Q

Investigations: labs
- Smoking gun?

A

D dimer

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8
Q

Investigations: D dimer
- When should it be used?
- What to do if you get a positive result?

A

If there is a moderate to high probability of PE
Go straight to imaging

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9
Q

Investigations: labs
- What supportive tests?

A

Baseline FBC, UEC, LFT, coagulation studies

Troponin: may be a low grade rise

ABG: if low PO2

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10
Q

Investigations: imaging
- What are the 2 modalities?

A

CT pulmonary angiogram
VQ scan

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11
Q

Investigations: imaging
- What is the finding of PE in each?
- Why might a VQ scan be used instead of a CT PA?

A

CT PA: filling defects
VQ scan: area of ventilation that is not perfused

VQ scan would be used if:
- The patient has poor lung function (smoker, COPD etc)
- Pregnant
- Renal impairment or contrast allergy

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12
Q

Management
- If hemodynamically unstable?

A
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13
Q

Management
- Ongoing management?

A

Anticoagulants
- DOACs: apixaban and rivaroxaban (factor Xa inhibitors)
- LMWH : enoxaparin (Clexane) - if contraindicated to the above

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14
Q

Management: ongoing
- Timing of anticoagulation if the PE is unprovoked versus provoked?

A

Provoked: can usually stop anticoagulants after 3 months
Unprovoked: ongoing

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15
Q

Management:
Treatment if contraindicated to anticoagulants, or recurrent VTE despite adequate anticoagulation therapy?

A

IVC filter

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16
Q

Explaining a PE to a patient

A
17
Q

Explaining to a patient
- Anticoagulation
- Thrombolysis
- Percutaneous catheter directed thrombolysis
- Surgical embolectomy

A

Anticoagulation: stop the clot from growing, so it can naturally break down.
Thrombolysis: dissolving the clot; given via IV
Percutaneous catheter directed thrombolysis: via a thin tube (catheter) to the clot directly
Surgical embolectomy: surgery to remove the clot