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Respiratory > Pulmonary embolism > Flashcards

Pulmonary embolism Flashcards

1
Q

What is a PE?

A

Formation of a thrombus in the pulmonary arteries

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2
Q

What are the main risk factors of PE?

A

Immobility

Recent surgery

Pregnancy (due to hypercoagulable state)

Long-haul flights

Malignancy

Hormone therapy with oestrogen

Polycythaemia

Thrombophilia

Anti-phospholipid syndrome

SLE

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3
Q

How can PE present?

A

SOB

Pleuritic chest pain (i.e., pain on inspiration)

Cough (with or without haemoptysis)

Tachycardia

Hypoxia

Reduced RR

Low grade fever

Haemodynamic instability causing hypotension

Could also see signs of DVT e.g., unilateral leg swelling + tenderness

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4
Q

Who should you do a VTE assessment for?

A

Every patient that is admitted to hospital

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5
Q

What should you give patients that are at high risk of VTE (after completing a VTE assessment)?

A

Prophylactic low molecular weight heparin e.g., Enoxaparin

Anti-embolic compression stockings

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6
Q

What are the contraindications for LMWH?

A

Active bleeding

Existing anti-coagulation with warfarin or NOAC

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7
Q

What is a major contraindication for compression stockings?

A

Peripheral artery disease

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8
Q

What is the Well’s score?

A

A scoring system that predicts the risk of a patient having a DVT or PE

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9
Q

According to NICE guidelines what is the cut-off Wells score for a patient having a likely PE?

A

> 4 points

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10
Q

According to NICE guidelines what imaging should be offered immediately for people with likely PE?

A

CTPA

If allergic to contrast (or for patients with severe chronic renal impairment (eGFR <30 ml/min/1.73 m2) or acute renal impairment) = V/Q scan (i.e., ventilation perfusion scan)

Could also do CXR - oligaemic crisis

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11
Q

If you can’t do imaging immediately what should you do instead?

A

Interim anticoagulation

Choose an anticoagulant that can be continued if PE is diagnosed e.g., apixaban or rivaroxaban

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12
Q

What tests should be done before starting people on anticoagulants?

A

Baseline bloods = FBCs, renal function, liver function, PT and APTT

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13
Q

TRUE or FALSE

Before starting interim anticoagulation you must wait for the blood test results

A

FALSE

NICE guidelines states:

do not wait for the results of baseline blood tests before starting anticoagulation treatment

review, and if necessary act on, the results of baseline blood tests within 24 hours of starting interim therapeutic anticoagulation

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14
Q

What is the conventional Tx of PE?

A

Apixaban or Rivaroxaban

If neither are suitable then offer:

LMWH for at least 5 days followed by dabigatran or edoxaban

LMWH concurrently with a vitamin K antagonist (VKA) - e.g., warfarin for at least 5 days, or until the INR is at least 2.0 in 2 consecutive readings, followed by a VKA on its own

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15
Q

Should you routinely offer unfractionated heparin + vitamin K antagonists (VKA) (e.g., warfarin) to patients with PE?

A

NO

Unless they have renal impairment/established renal failure or increased risk of bleeding

(NICE GUIDELINES)

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16
Q

Should you routinely offer self-monitoring of INR to patients on VKA?

A

No

(NICE GUIDELINES)

17
Q

If the Wells score is 4 or less what should you do?

A

D-dimer (a -ve test can reliably exclude PE)

If positive do a CTPA

18
Q

What are the disadvantages of D-dimer?

A

Sensitive for other diseases too.

Will be raised in hypercoagulable states e.g., infection/inflammation, pregnancy

19
Q

What are D-dimers?

A

Protein products of cross-linked fibrin degradation

Fibrin is an essential component of blood clots

20
Q

What are the options for long term anticoagulation in PE?

A

DOACs

Warfarin

LMWH

21
Q

What is the first line drug for long term anticoagulation in pregnancy or cancer?

A

LMWH

22
Q

What is the target INR for warfarin?

A

2 - 3

23
Q

What is used in the bridging therapy for when a patient is started on warfarin? How long?

A

LMWH

For 5 days

OR

Until INR is 2-3 for 24 hours on warfarin

24
Q

How long should you anti-coagulate for the different causes of PE?

A

Provoked = 3 months

Unprovoked = 6 months (in clinical practice sometimes this can be extended to lifelong)

Active cancer = 6 months (then review)

25
Q

When is thrombolysis used?

A

Massive PE with haemodynamic compromise

26
Q

What does thrombolysis involve?

A

Injection of fibrinolytic injection e.g., alteplase, streptokinase, or tenecteplase

27
Q

What are the two ways thrombolysis can be performed?

A

IV - using cannula

Directly into arteries - using a central catheter i.e., catheter directed thrombolysis

28
Q

How is catheter directed thrombolysis done? What is a major risk?

A

Catheter is inserted into the venous system, through the right side of the heart and in to the pulmonary arteries

Administrator administers thrombolytic agent directly to where the thrombus is

MAJOR RISK = pulmonary artery damage

29
Q

How is a V/Q scan carried out? How will a PE appear?

A
  1. Isotopes are inhaled to fill the lungs and a picture is taken = VENTILATION.
  2. Contrast containing isotopes is injected and a picture is taken = PERFUSION.

PE will show deficit in perfusion because thrombus blocks blood flow to the lung tissue

30
Q

What is the hallmark finding of PE on ECG

A

S1Q3T3

31
Q

What would be ABG findings and why?

A

Respiratory alkalosis

Tachypnoeic patients blow off a lot of CO2 causing the PaCO2 to drop and the pH to drop

NOTE: the other main cause of respiratory alkalosis is hyperventilation syndrome

32
Q

Sources

A

https://zerotofinals.com/medicine/respiratory/pe/

https://acutecaretesting.org/en/journal-scans/causes-of-increased-d-dimer/

https://www.nice.org.uk/guidance/ng158/chapter/Recommendations#diagnosis-and-initial-management

https://www.nice.org.uk/guidance/ng158/resources/visual-summary-pdf-11193380893

https://www.rcr.ac.uk/sites/default/files/Intravasc_contrast_web.pdf

Respiratory (10 decks)

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