TOPIC41: pulmonary embolism Flashcards

1
Q

what is PE?

A

-Occlusion of one or more arteries by a thrombi that originated elsewhere, typically in the deep veins on the lower extremities/pelvis

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2
Q

Etiology of PE

A
  1. DVT (95%)
    - Prolonged bed rest, surgery, severe trauma(burns, fractures), congestive HF, oral contraceptives( high estrogen) or hypercoaguable state
  2. upper extremity veins (Central venous catheters)
  3. Right sided heart chamber dilation.
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3
Q

Risk for PE

A
  1. Venous stasis: immobility, surgery, planes, obstruction, CHF
  2. Vein damage: local trauma, previous thrombosis/phlebitis
  3. hypercoaguable state
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4
Q

heart and lung signs of PE

A
after the thrombus blockage:
A.lungs:
1. increased pulmonary artery pressure (and resistance)
2.atelectasis
3.decreased surfactant
4.reflex tachypnea
5.hypoxemia

B. heart:

  1. diminished CO because the blood cannot flow to the left ventricle
  2. blood will back behind causing cor pulmonale
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5
Q

Signs and symptoms of PE

A

SMALL EMBOLI: automatically lysed–> no symp.

LARGER: Dyspnea, chest pain, cough, hemoptysis, altered mental status

MASSIVE: hypotension,reflex tachycardia, cyanosis, syncope, cardiac arrest

if VRF: Distended IJV with or without tricuspid regurgitation

DVT: leg edema, tenderness, erythema, pain on flexing ankle

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6
Q

Clinical picture in PE (types according to severity)

A
  1. acute massive
  2. subacute: recurrent emboli
  3. acute minor: dyspnea, pleuritic pain, hemoptysis, fever
  4. chronis: PHTN, chronic cor pulmonale
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7
Q

Diagnosis of PE (2 EXCLUSION, 6 SPECIFIC)

A

A.general for exclusion:

  1. MI:
    - ECG–>tachycardia, S1Q3, right heart strain (repolarisation abnormalities due to hypertrophy or dilation)
  2. aortic dissection:
    - CXR:normal or effusion, atelectasis, opacity if infarction
    - ABG: decreased pO2, pCO2–> hypoxemia and hypoventillation

B.Specific:

  1. CT pulm angio
  2. ventillation/ perfusion lung scan–> detect areas that are ventillated but not perfused
  3. D-dimer: increased (indicates fibrinolysis)
  4. lower extremity US
  5. Troponin is increased if there is right ventricular strain
  6. BNP: decreased indicates better prognosis than increased (measure level of HF)
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8
Q

Therapy for PE

A
  1. Initially:
    - supply oxygen
    - IV saline (hypotension)
    - vasopressors (stop tacchy)
    - anticoagulation (stop further coag)
    - morphine (stop pain)

2.Consider clot elimination:
a. Embolectomy
b. thrombolytic therapy (with tPA, streptokinase, urokinase eg streptokinase infusion for 24hr + hydrocortisone for side effects)
Heparin should always be added

  1. Anticoagulation:
    - heparin IV 5000units bolus + 1000-2000 units/hr continuous infusion or LMWH subcutaneously (high dose)
    - Warfarin for long term 3 weeks to 6 months
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9
Q

Prophylaxis for PE

A
  • compression stockings
  • LMWH
  • avoid contraceptive pills if at risk
  • vena cava filters of limited use
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