Week 219 - Haemoptysis (PE)

Question 1

Name the 3 parts of Virchow’s Triad for thrombosis

Answer 1

• Blood stasis
• Vessel injury
• Hypercoagulability

Question 2

Name 3 ways in which a vessel may be injured to increase risk of thrombosis

Answer 2

• Atherosclerotic plaque formation
• compression from tumour
• Vessel trauma

Question 3

List the main symptoms of DVT

Answer 3

Calf tenderness/pain; Calf swelling; Heat; Redness; difficulty of pain on dorsiflexion; none

Question 4

What is Homan’s sign?

Answer 4

An indication of DVT, pain or difficulty on dorsiflexion

Question 5

What is Well’s Score?

Answer 5

A probability calculator for the likelihood of a DVT

Question 6

List the risk factors for DVT

Answer 6

Malignancy (within last 6 months); Immobility; Surgery (particularly on leg or pelvis); previous DVT; hypercoagulable states e.g. thrombophilia; pregnancy; FHx; long-hall flights; Synthetic Oestrogen; Age; Obesity

Question 7

What is the first investigation you should do to detect DVT?

Answer 7

Doppler Ultrasound (CT rarely used!)

Question 8

What is a D-dimer test?

Answer 8

A test of the level of D-dimer in the blood. D-dimer is a breakdown product of cross-linked fibrin - it is elevated in thromboembolism.

Question 9

What do D-dimer results tell you?

Answer 9

A negative result virtually excludes DVT. A positive result requires further investigation as D-dimer is also elevated in: post surgery, trauma, liver / renal disease, pregnancy, cancer, heart diseases etc.

Question 10

What is the management for DVT?

Answer 10

LMWH (enoxaparin/heparin) until Dx confirmed; Doppler USS next day; Cont. heparin until INR ~2.5; then Warfarin 3/12 if clear cause - if no clear cause 6/12

Question 11

Why is pulmonary infarction not an invariable consequence of PE?

Answer 11

Due to the dual blood supply to the lung parenchyma: bronchial and pulmonary

Question 12

What causes the 10% of haemoptysis in PE

Answer 12

Necrosis of lung parenchyma due to pulmonary infarction

Question 13

What are the principle symptoms of PE?

Answer 13

Acute/subacute SOB; pleuritic chest pain; dizziness; syncope; restlessness/anxiety; haemoptysis (~10%)

Question 14

What are the cardinal SIGNS of PE?

Answer 14

Dyspnoea; Tachypnoea; Pleuritic pain

Question 15

List other signs that frequently present with PE

Answer 15

Tachycardia; Cyanosis; Pyrexia; AF; signs of recent surgery; raised JVP; Hypotension; Pleural rub; Loud/Widely split 2nd heart sound (P2)

Question 16

Describe the main difference between a normal clot and a pathological clot?

Answer 16

A normal clot is porous to allow plasmin in to breakdown the fibrin mesh. A pathological clot (e.g. that seen in a Pt with malignancy) is a much tighter mesh of fibrin making it difficult for plasmin to break down

Question 17

What is atelectasis?

Answer 17

Where one or more areas of the lung don’t inflate properly

Question 18

What might you see on a CXR of someone with PE?

Answer 18

Nothing; linear shadow; Peripheral wedge;small effusion; elevated diaphragm; Paucity of vessels; Small cavity/abscess

Question 19

What changes might you see on an ECG with PE?

Answer 19

Sinus tachycardia; ST / T wave changes in V1-V3; Right axis deviation; S1, Q3, T3 (large S wave in lead I, large Q wave in lead III and T wave inversion in lead III)

Question 20

What is considered the gold standard for imaging investigation of PE?

Answer 20

CT pulmonary angiography (sensitivity >95%)

Question 21

What is the reason for often seeing Rt axis deviation on an ECG with PE?

Answer 21

Enlarge right side of heart due to increased pressure

Question 22

What imaging might a woman opt for over a CTPA in the investigation of PE and why?

Answer 22

a Ventilation / Perfusion scan - less radiation, effective on those without previous lung disease. Cost effective though low, med, high prob diff to interpret

Question 23

What other investigation might be helpful with massive PE prior to thrombolysis?

Answer 23

ECHO - may show: cardiac compromise; RV overload (cannot exclude small PE)

Question 24

What is a Pesi Score?

Answer 24

Predicts 30 day outcome of Pts with PE

Question 25

What is the immediate management for PE?

Answer 25

High flow O2; IV fluids; analgesia (for pleuritic pain)

Consider unfractionated heparin - in unsure give! clexane whilst investigate; thrombolysis if early (12-24 hours)

Question 26

What is the long term Mx of PE?

Answer 26

Once Dx confirmed: Warfarin - aim for INR of 2-3

IVC filter placement (rarely)