Venous Thromboembolism (VTE) - Pulmonary Embolism (PE)

Question 1

What is a Pulmonary Embolism?

Answer 1

Dislodging of a Thrombus and its travel through the right side of the heart into the pulmonary circulation.

Question 2

Clinical Presentation of PE.

Answer 2

1. SOB.
2. Cough (+/- Haemoptysis).
3. Pleuritic Chest Pain.
4. Hypoxia.
5. Raised Respiratory Rate & Haemodynamic Instability.
6. Low Grade Fever.

Question 3

Exclusion of PE.

Answer 3

PERC Criteria - PE Rule-Out Criteria (all must be absent for a probability less than 2%).

Question 4

Diagnosis in PE (2).

Answer 4

1. CT Pulmonary Angiogram (CTPA).

2. V/Q Scan (indication : significant kidney impairment, contrast allergy).

Question 5

Wells Score of PE - Investigations.

Answer 5

1. Likely (5+) - CTPA (Delay - Interim Therapeutic Anticoagulation) and if CTPA is negative, Proximal Leg US (if DVT is suspected).
2. Unlikely (<5) - D-Dimer (if Positive = CTPA).

Question 6

Procedure of CTPA.

Answer 6

Chest CT Scan with IV contrast.

Question 7

Procedure of V/Q Scan.

Answer 7

Radioactive Isotopes (inhaled and injected) and a Gamma Camera to compare ventilation and perfusion

Question 8

ABG Finding of PE.

Answer 8

Respiratory Alkalosis.

Question 9

ECG Findings of PE.

Answer 9

1. Normal/Sinus Tachycardia.
2. Evidence of Right Heart Strain e.g. P-Pulmonale, RAD, RBBB.
3. Rare : S1Q3T3 (Deep S waves in Lead I, Pathological Q Waves in Leads III, Inverted T waves in Lead III).

Question 10

CXR Findings of PE.

Answer 10

1. Normal.
2. Fleischer Sign (Enlarged Pulmonary Artery).
3. Hampton’s Hump (Peripheral Wedge Shaped Opacity).
4. Westermark’s Sign (Regional Oligaemia).

Question 11

Management of Massive PE & Haemodynamic Compromise.

Answer 11

Thrombolysis - Fibrinolytic Medication to rapidly dissolve clots either IV Peripheral Cannula or Catheter-Directed Thrombolysis (directly into pulmonary arteries using central catheter).
Alternative : Embolectomy.

Question 12

Examples of Thrombolytic Agents.

Answer 12

1. Streptokinase.
2. Alteplase.
3. Tenectaplase.

Question 13

Contraindications of Thrombolysis (5).

Answer 13

1. Previous Intracranial Haemorrhage.
2. Recent Ischaemic Stroke (<3 Months).
3. Recent Head Injury.
4. Recent Surgery.
5. Bleeding Disorder/Active.