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Year 2 PBL > U12: Pulmonary embolism > Flashcards

U12: Pulmonary embolism Flashcards

1
Q

Describe the basic pattern of pulmonary circulation

A

Deoxygenated blood is pumped from the right ventricle into the pulmonary trunk into pulmonary circulation
Blood is oxygenised then returned to the left atrium via the pulmonary vein.

Bronchial arteries provide systemic circulation to the lungs, provide oxygenated blood are a branch of the descending thoracic aorta, deoxygenated blood drains via the bronchial veins back into the pulmonary vein or the azygous vein.

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2
Q

What is the difference between a venous thromboembolism, PE and DVT?

A

Venous thromboembolism - starts in vein and moves
PE - emboli in pulmonary circulation
DVT - thrombus originating in a deep vein in the leg.

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3
Q

What are the risk facotrs of venous thromboembolism in Virchows triad?

A

Endothelial INjury
Abnormal Blood flow
Hypercoagulability

(note endothelial injury and abnormal blood flow have a bidirectional causative relationship)

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4
Q

What are some of the risk factors for pulmonary embolism?

A

Immobility - prolonged bed rest/ sitting
Local venous disorders - varicosities
Surgery - mainly hip or pelvic
Malignancy
Obesity
Breast cancer
Pregnancy (inc coag factors and decreased venous leg circulation)
Long bone fractures
Contraceptive pill use
Heart failure (vascular stasis)
Thrombophilic conditions (factor V ledine or prothrombin mutation)

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5
Q

What are some of the transient risk factors for a venous thromboembolism?

A

Surgery - lower limb, pelvis
Trauma
Active cancer
Acute medical admission
Immobilisation
Plaster cast
Pregnancy
Osteogen administration
Recent long haul travel
Central venous catheter
Heparin- induced thrombocytopenia
Superficial vein thrombosis

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6
Q

What are some of the persistent risk factors for venous thromboembolism?

A

Increasing age
BMI above 30
Ethnicity
Previous VTE
INflammatory conditions - SLE
Nephrotic syndrome (inc liver activity)
Lower limb paresis
Antiphospholipid syndrome
Myeloproliferative neoplasms

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7
Q

What is the basic process of thrombosis?

A

Pathological process by which a localized solid mass of blood constituents (thrombus) forms within a blood vessel, mostly a result of fibrin formation with a variable contribution from platelets and other cells.

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8
Q

How does endothelial injury increase risk of thrombus?

A

Promotes platelet adhesion and aggregation (decreased NO and PGI2)
Causes the production of pro-coagulant factors (activation of extrinsic and intrinsic coagulation cascade)

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9
Q

How does abnormal blood flow increase the risk of thrombus formation?

A

Prevents blood diluting factors from reaching site
Stasis (venous thrombosis) - allows platelets to encounter endothelium due to loss of laminar flow and slows the washout of activated clotting factors
Turbulence (arterial, near valves) - caused by physical trauma to endothelial cells of dysfunction, countercurrent and local pockets of stasis.

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10
Q

How does a hypercoagulable state increase the risk of a venous thrombus?

A

Increases the concentration of fibrinogen and prothrombin

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11
Q

What are the primary causes of a hypercoagulable state?

A

Leiden factor V mutation (resistance to inactivation from Protein C)
Congenital deficiency of antithrombin III, protein C and S

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12
Q

What are the secondary causes of a hypercoagulable state?

A

Immobilisation, MI, neoplasia, tissue damage (surgery, fracture, burns), cancer, prosthetic cardiac valves
Heparin induced thrombocytopaenia syndrome
Antiphospholipid antibody syndrome

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13
Q

What are the features of an arterial thrombus?

A

Secondary to atheroma (turbulent blood flow and narrowed lumen)
Consists of platelets
Commonly found in the brain (MCA) and the coronary arteries
Often a result on endothelial injury

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14
Q

What are the features of a venous thrombus?

A

Slow blood flow, low pressure (stasis)
Mainly made from red cells, platelets and fibrin
Commonly found in red cells, platelets and fibrin
Deep calf veins (can embolise to lungs)
Hepatic portal vein

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15
Q

What are the distinctive gross features of an arterial thrombus?

A

Lines of Zahn
Lamination of fibrin and platelets

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16
Q

What are the different fates of a thrombus?

A

Lysis - intrinsic thrombolytic activity of the blood
Propagation (increase in size) - focus for further thrombosis
Organsiation - invaded by connective tissue (firm and grey)
Canalisation - new lumen lined by endothelial cells forms
Emboliszation - dislodges travels through circulation and comes lodged somewhere else.

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17
Q

What is the most common type of embolism?

A

Thromboembolism
95% from deep vein leg, 5% from pelvic veins

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18
Q

What are the fates of emboli based on their different size?

A

Small emboli - increase pulomonary arterial pressure (pulmonary hypertension)
Dead space (ventilated but not perfused) cause SOB, and potentially pulmonary infarction which presents as chest pain and haemptysis.
A massive embolus can cause sudden death.

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19
Q

How can PE cause pulmonary haemorrhage?

A

Embolic obstruction of medium-sized arteries and subsequent rupture of downstream capillaries deemed anoxic can cause pulmonary haemorrhage
Such emboli do not usually cause pulmonary infarction because of dual circulation.

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20
Q

How can a PE cause a pulmonary infarct?

A

Unlikley in pulmonary artery as this is deoxygenated blood anyway and supplied by bronchial arteries
In left-sided emboli aka in the bronchial artery can cause an infarction.

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21
Q

What are the key clinical signs and symptoms of a DVT?

A

Pain and swelling in one leg
Red and warm to the touch.
Tenderness along the course of the deep veins and dilation of the superficial veins
Dorsalis pedis pulse may be missing in one limb if vasospasm of the vessel has occurred secondary to obstructed veins
Homans sign - sharp dorsiflexion of the foot with knee extended causes pain in the calf resulting from tension in soleus and gastrocnemius muscle

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22
Q

What are the common symptoms on a pulmonary embolism?

A

Pleuritic chest pain - worse on inspiration
Breathlessness - often worse on exertion (sometimes this is the only symptom)
Haemoptysis
Tachypnoea
Tachycardia
Crackles and pleural rub over localized area of pulmonary infarction

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23
Q

What are some rare symptoms of a pulmonary embolism?

A

Syncopal episodes
Systolic hypotension
Shock
Myocardial ischemia associated with central chest pain
Rasied jugular venous pressure with a prominent a-wave, right ventricular heave, gallop rhythm and a widely split 2nd heart sound (inc pressure in RA/V delays closing).

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24
Q

What is important to remember about the presentation of DVT and PE?

A

A patient may have a DVT and may/may not have a PE and vice versa
The patient ay only have symptoms of one and the other may be clinically silent.

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25
Q

What is the most frequent sign and symptom of PE?

A

Symptom - dyspnoea
Sign - tahcypnoea

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26
Q

What symptoms indicate a PE is more likely to be massive?

A

Dyspnoea
Syncope
Hypotension - reduced left heart filling
Cyanosis - due to low Po2

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27
Q

What indiciates a PE is more likley to be small and near the pleura?

A

Pleuretic chest pain
Cough
Haemoptysis

28
Q

How may young/healthy individuals present with a PE?

A

Appear anxious but other wise unwell.

29
Q

What is the Wells score for PE?

A

The two-level system:
Score above 4 indicate PE is likley and score of 4 or below indicates PE is unlikely.
Score 3 for s/s of DVT
3 for alternative diagnosis being less likely
1.5 for HR above 100bpm
1.5 for immobilisation for 3days + or surgery in last 4 weeks
1.5 for previous DVT/PE
1 for haemoptysis
1 for malignancy or in past 6 months

30
Q

What is the Wells Score for DVT?

A

Two level system score is 2 or above indicates DVT is likely, score is one or below DVT is unlikely
Score one mark for - active cancer, paralysis, reduced/immobile in lower extremities.
Recent bedridden or major surgery
Localised tenderness along the distribution of the deep venous system
Entire leg swollen
Calf swelling at least 3cm larger than symptomatic side
Pitteinf odeme on symptomatic side
Collateral superficial veins
Previously documented DVT
Minus two point if an alternative diagnosis is more or equally as likley

31
Q

What investigations might you order for a DVT/PE?

A

Arterial blood gas
D-dimer
ECG
CXR
CTPA
V?Q scanning
Lower limb compression venous ultrasound
Echocardiography

32
Q

What does an arterial blood gas result look like for a PE?

A

Most patients present with: hypoxemia, hypocapnia and respiratory alkalosis
However, an acute massive PE can present with Hypercapnia and hypoxima and acidosis.

33
Q

What is the use of D-dimer in a thromboembolism patient?

A

Used as a negative result to exclude thromboembolic in low risk diagnosis.

34
Q

What do ECG results look like in a pulmonary embolism?

A

Tachycardia most common
May also find right ventricular strain and right bundle blocks
S1Q3T3 pattern is textbook but uncommon (deep S wave on lead 1, Q waves and inverted T waves in lead 3)

35
Q

How might a chest x-ray indicate pulmonary embolism?

A

Usually normal but may show atelectasis (due to reduced surfactant production) or small wedge shadow (Hampton hump - shows area of infarcation)

36
Q

What is the gold standard diagnostic test for a PE?

A

CT pulmonary angiogram

37
Q

How might a PE present in echocardiography?

A

Evidence of acute right ventricular dystrophy (larger and thicker walls)
Enlarged pulmonary trunk.

38
Q

What is the diagnostic protocol for someone with a suspected DVT?

A

Assess clincal probability by 2-level Wells score
DVT unlikely - do D-dimer to rule out, if raised do ultrasound of veins
Is DVT likely - ultrasound veins, if positive DVT, if negative order D dimer and repeat ultrasound 5-7 days later if raised.

39
Q

What is the diagnostic protocol for somone with suspected PE with shock or hypotension?

A

If CT pulmonary agniogram available order one
If not have a bedside echocardiogram, is RBdysfunction indicated start PE treatment in CTPA still not available

40
Q

What is the diagnostic protocol for a patient with a suspected PE without shock/hypotension?

A

Assess clincal probability by two-level wells score
PE likely order a CTPA
PE unlikely order D-dimer, if positive order a CT pulmonary angiogram

41
Q

What is the normal management of venous thrombo embolism?

A

Anti-coagulant therapy
1. Acute phase - lasting 5 to days
2. Maintenance phase lasting a minimum of 3 months
3. A long term phase beyond this
The goal of treatment is to prevent embolisation and thrombus recurrence

42
Q

What are the NICE guidelines for PE management?

A

Initial assessment should follow ABCDE
If DVT or PE confirmed treat with LMWH or fondaprinus, or if have renal impairment or increased risk of bleeding offer UFH or LMWH
If hemodynamically unstable with a PE should consider thrombolytic theapr or embolectimy
Should continue subcutaneous or intravenous anti-coagulation for a minimum of five days or until the INR raio is 2.0 or more for 24hrs+

43
Q

What anti-coagulant should be given is the patient has an increased risk of haemorrhage?

A

Unfractionated Heparin

44
Q

When should the risk benefit ratio be re-assessed for patients with a PE?

A

3 months after treatment was started.

45
Q

What is the use of Inferior Vena cava filters in PE patients?

A

Implantable devices used for patient with contraindication to anticoagulants or those with recurrent thromboembolism despite adequate drug therapy.

46
Q

What is the purpose of the gender Recognition Act?

A

Enacted in 2004
A UK law that allow people with gender dysphoria to change their legal gender by applying for a Gender Redcongition Certificate.
Originally cost was £140, this has now been changed to £5.

47
Q

What are the criteria to obtain a Gender Recognition Certificate?

A

A medical diagnosis of gender dysphoria
A report from medical professional detailing any medical treatment
Evidence of living in gender for last two years
A statutory decleration that they intend to live in acquired gender until death
If married consent of spouse/civil partner
Payment fee of £5
Submission of document to a panel.

48
Q

What is meant by deadnaming for a transgender patient?

A

The use of a transgenders person birth name without consent
This can upset patients and impeded the doctor-patient relationship

49
Q

What is the relationship between the oral contraceptive pill and DVT?

A

Oestorgen as a steroid hormone can alter gene expression and increase the amount of pro-coagulant proteins and decrease the amount of anti-coagulant proteins.

50
Q

What is meant by a thready pulse?

A

One that is difficult to feel or easily obliterated by light pressure

51
Q

Why did pulmonary embolism lead to gastric ulceration?**

A

Anti-coagulant treatment such as NSAIDs - large increase in bleeding risk from ulcers
Stress response - increased cortisol and adrenaline increase gastric acid secretion and decrease blood flow to the GIT
May have shared risk factors - smoking, alcohol, etc

52
Q

What is meant by a central saddle embolism?

A

Rare type of PE
Can lead to sudden hemodynamic collapse and death
Visible thrombus located at the bifurcation of the main pulmonary arterial trunk, normally associated with hemodynamic instability.

53
Q

What is the basic process behind a basic blood transfusion?

A

Can only be requested by a doctor or Registered Nurse.
Paperwork must be complete and signed
Patient should have a blood sample taken for a save and cross match - to ensure the correct blood type is given
If able patient should be informed and give written consent for the procedure
In an emergency situation may activate major hemorrhage protocol for quickly deliver of no cross reactive blood (type O rhesus negative)
Blood is given into a vein
All donor blood is screened for Hep B and HIV before it can be used.
Patients can be given blood components, blood products or a whole blood tranfusion.
It can take up to four hours to receive one bag of blood but this is often done faster.

54
Q

What are the common side effects of a blood transfusion?

A

Fever, chills, itching, rash and sore injection site are common after a blood transfusion - often created with paracetamol
Respiratory distress, High fever, hypotension and red urine can indicate a more serious reaction.

55
Q

What is the link between PE/DVT and severe bowel incontinence?

A

Thrombus in IVC increase pressure in anterior epidural veins - swell with pressure and can cause cauda equina syndrome.
Compression of nearby nerves - bowel dysfunction
Ischemia of bowel due to pressure in veins occluding arteries - bowel incontinence
Pelvic congestion syndrome - increased pressure on bowel, increased risk of uncontrolled defecation.

56
Q

What are some contraindications to the treatment given for thromboembolism?

A

Moderate to severe renal impairment
Significant risk of major bleeding such as recurrent GIT ulcer
Recent intracranial haemorrhage
Aneurysm

57
Q

What are some adverse effects of treatment for thromboembolism?

A

Haemorrhage
Heparin-induced thrombocytopenia
Anemia
Fatigue

58
Q

What is the difference between an IV bolus and an infusion?

A

IV bolus - give a single dose of a medication over a short time (minutes), gives a small volume of a high concentration, can be given as a single dose, repeated dose, weight based dosing or titration - in which bolus continues to be given until desired effect is reached
IV infusion - takes longer as relies on gravity, continuous administration over a long period of time, diluted to a large volume of fluid

59
Q

What is the use of a combined oral contracetive in transgender patients?

A

Prevent pregnancy
Prevent periods - distressing and dymorphia inducing
Testosterone given to trans gender males does not effect the efficacy of emergency hormonal contraceptives.
Mainly used by people who still have a uterus and/or ovaries
Note progesterone only pill is recommended if the patient is also taking hormonal therapy as oestrogen may interfere with their transition.

60
Q

What is the difference between a gastric erosion and a deep ulcer?

A

Gastric ulcers - full thickness los of gastric mucosa
Gastric eorsion - partial loss of mucosa, preservation of the muscularis mucosae.
Ulcers are larger than 5mm in size

61
Q

What happens at a post-mortem examination?

A

Medical examination done by pathologists to find the persons last illness and cause of death.
May be required by a coroner and are required by law so do not need agreement from a loved one, consented/hospital post mortems are requested by doctor/loved on and require loved on consent.
Usually occur within 2-3 working days of the death
Occurs in the mortuary
All body systems including the brain are examined, some tissue samples are taken for examination under a microscope.
Results are normally available within 6 weeks
You may arrange for tissue/slides to be returned to you for burial or cremation by the hospital. If not requested tissue samples are cremated in 30 years
The body is returned to you after the post-mortem is completed and you can view the body if you wish.

62
Q

What is the definition of brain death?

A

Brain death - when a person on artificial life support no longer has any brain functions, they will not regain consciouensses or be able to breathe without support - this is legally confirmed as dead as their body would be unable to survive without artificial support.
Must be diagnosed by two doctors, one of which senior, no involvement in the transplant team.
Patient will undergo a series of tests twice before diagnosis, this includes the gag reflex and the pupillary reflexes.

63
Q

Death is defined by NCBI as?

A

Irreversible cessation of circulatory and respiratory functions
Irreversible cessation of all functions of the entire brain including the brain stem is dead.

64
Q

What decision making is included when deciding to attempt resuscitation?

A

If possible anticipatory decisions should be made by the patient or their relatives, attorney if the patient lacks capacity - this is often in the form of advanced care planning before a crisis occurs (ADRT)
Reviews in any advance decision should be frequent enough to consider a change in the patients circumstance, acute illness and general health.
A DNACPR should be respected if noted, should be clearly informed to all ward staff responsible for the patient and denoted on their notes.
If there is a clear clinical need for a DNACPR in a dying patient with CPR offers no realistic prospect of success that decision should be made in discussion with the family and patient as soon as possible.
Consent is not required for a doctor to issue a DNACPR but a second opinion can be requested.

65
Q

Under what conditions might resuscitation not be attempted?

A

Asystole for 20 minutes in absence of reversible cause and in presence of advanced life support.
May decide to stop if rhythm is not shockable (not on its own) and the cause for arrest persists.
If the patient is extremely frail, would be in pain after resuscitation and would not prolong life.

66
Q

What is the impact of sudden death on a family?

A

Stages of grief: denial, anger, bargaining, depression, acceptance
Strain on relationships and mental wellbeing.
many unresolved questions - guilt and pain - require support from friends, religious figures etc
Parents often describe feeling a loss of purpose and security
Struggle to accept that society and other people will move on.

Year 2 PBL (27 decks)

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