Week One - Case Two Flashcards by Rosa Birt

what is a pulmonary embolism most common secondary to

a VTE from another source that becomes dislodged, flows via bloodstream, through the right side of the heart and gets lodged into the pulmonary circulation

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what is the mortality rate of PE with VTE if there is no haemodynamic instability

<5%

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what is the mortality rate of a PE with VTE if shock is present

30%

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what is the mortality rate of a PE with VTE if cardiac arrest happens

70%

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what are the risk factors for a PE

age

Malignancy

Infection

Family history

Immobility
Bed rest >24 hours
Immobility >48 hours
Plaster of Paris over limbs

pregnancy - oestrogen (4 weeks after birth)

Previous DVT

Trauma or surgery

Dehydration

Smoking

Congestive heart failure

Antithrombin and protein C
deficiency

Obesity

Varicose veins

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what are the signs of a PE

Pyrexia

Cyanosis

Tachypnoea

Tachycardia

Hypotension

Raised JVP

Pleural rub

Pleural effusion

Look for signs that could indicate a cause – e.g. DVT, recent surgery, air travel –

Atrial fibrillation (rare)

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what percentage of people have tachypnoea with a PE

90% of patients have RR>16

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what percentage of people have tachycardia with a PE

45%

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what percentage of people have hypotension with a PE

25%

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what are the most common symptoms of a PE

Pleuritic chest pain (pain worse on inspiration) –75% of patients

Breathlessness –85% of patients

Cough –50% of patients

Haemoptysis – as a result of pulmonary infarct –30% of patients

Dizziness / pre-syncope –15% of patients

Syncope (loss of consciousness/fainting) –15% of patients

Non-pleuritic chest pain – 15% of patients

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what is the first symptom to occur

shortness of breath occurs within seconds and pain develops later

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what is the PERC score used for diagnosis

stands for pulmonary embolism rule-out criteria

it is useful to rule out PE in low risk patients

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what happens if patient’s PERC score is 0

there is less than 2% chance of PE

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how is PERC score scored

Each factor below gives a score of 1. All factors must be negative for a negative PERC score. Any positive factor results in the need for further work up (move onto the Well’s Score)

Age >50
HR >100
SaO2 on room air <95%
Unilateral leg swelling
Haemoptysis
Recent surgery or trauma
Previous PE or DVT
Exogenous Oestrogen

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what is the Well’s Score for PE

this can stratify patients as low risk or high risk.

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what should happen with low and high risk patients

with high risk patients you should proceed straight to imaging

in low risk patients you should consider a D dimer test

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look up the scores used in the Wells Score

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what is the traditional interpretation used of Well’s Score

Score >6.0 — High (probability 59%)

Score 2.0 to 6.0 — Moderate (probability 29%)

Score <2.0 — Low (probability 15%)

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what is the alternative interpretation of the Well’s Score

Score > 4 — PE likely. Consider diagnostic imaging.

Score 4 or less — PE unlikely. Consider D-dimer to rule out PE.

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what is D dimer

a fibrin deviation product - and as such, levels are raised by the presence of a blood clot in the circulation

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what does a negative D-dimer plus a low Well’s score mean

that PE or DVT is extremely unlikely

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when should a D dimer only be used

should only be used as a rule out test in low probability cases - based on the Well’s scoreb

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what does a positive D-dimer test in a low probability case indicate

the need for further investigation

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what should you do with a high probability case

skip the D dimer and go straight to imaging

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what, apart from a PE results in a positive D dimer

any factor that causes inflammation will also result in a raised D-dimer

when is a D-dimer test not appropriate as an investigation approach

if the patient recently had cellulitis or another infection

what happens with age to the D dimer value

D dimer also rises with age.

what is the traditional reference range for D dimer

normal <0.5 Example of age adjusted: Age <50 – normal <0.50 Age >50 – normal range is <0.50 PLUS 0.1 for every decade of life over the age of 50, e.g.: Age 60 – normal <0.60 Age 70 – normal <0.70

what other factors may cause an increased D dimer

Other factors that caused an increased D-Dimer include liver disease, high rheumatoid factor, malignancy, trauma, pregnancy and recent surgery.

what would a CXR normally look like in PE

often be normal the main reason it is performed is to exclude other causes

what are the potential, rare findings on a PE CXR

the CXR may show pulmonary oedema signs such as raised hemidiaphragm. May also show atelectasis - this is little areas of collapsed lung

why does this occur

because there is a loss of blood to some areas - a conservative mechanism

what raises the suspicion of a PE

if the CXR is normal but the patient is breathless

what happens if the CXR has bilateral changes, but the patient only has unilateral pain

this also raises the suspicion of a PE

what are the most common findings in ECG

T wave inversion and sinus tachycardia

what can large emboli cause to show on an ECG

cause right heart strain, which will result in the 'classical' S1Q3T3 pattern

what percentage of PE patents will have ECG changes

80%

what its the classical S1Q3T3 pattern

S waves present in lead I Q waves present in lead III T wave inversion in lead III

what is a CTPA

a CT-pulmonary angiogram CT with contrast, assessing the pulmonary blood vessels.

what is its main use

the diagnosis of a PE

what is the typical diagnostic scan used for a PE

a CTPA

are VQ or CTPA scans more accurate in diagnosing PE

CTPA -VQ scans are much less accurate the result of a VQ scan is usually given as a risk probability - high risk, intermediate risk or low risk

when would a VQ scan be used instead

as an alternative in young females, or pregnant females

what do the results of an ABG show

02 may be low C02 may often be normal or low

why is there low C02

the patient is hyperventilating

what is common seen in patients with a massive PE and cardiovascular collapse

metabolic acidosis

in what percentage of PE patients is troponin raise

20-40% as a result of the extra stress and stretch placed on the right ventricle with PE patients (due to increased pulmonary arterial pressure) higher troponin has been associated with a worse prognosis

what should a patient with signs of right heart strain and haemodynamic instability be considered for

thrombolysis

what is used for thromboylsis

50mg alteplase - long list of contraindications

what is a saddle PE

a PE sitting at the major bifurcation of the pulmonary veins

what is the other main treatment

anticoagulation

what can this be done with

warfarin, or a NOAC

what is an example of an NOAC

rivaroxaban

what is most favourable

NOAC as it dos not require monitoring and does not require the use of heparin at the start of the treatment period

what is an example of warfarin treatment

Anticoagulate with LMWH – e.g. dalteparin 200u/Kg/24hrs. The max dose is 18,000. At the same time start oral warfarin 10mg Stop the heparin when the INR is >2, and continue warfarin for a minimum of 3 months, aiming for an INR of 2-3.

when is a vena cava filter considered

in patients with recurrent thrombus despite anticoagulation, - but remember that implanting a filter without adequate anticoagulation will increase the risk of thrombus

what is the minimum amount of time for continuation of anticoagulant therapy

at the very minimum 6 weeks

what about those with an identifiable and reversible risk factor

3 months

what about those with idiopathic disease

6 months