Resp - PE Flashcards
What are some of the Absolute CI to Fibrinolysis?
-History of haemorrhagic stroke or stroke of unknown origin
-Ischaemic stroke in previous 6 months
-Central nervous system neoplasm
-Major trauma, surgery, or head injury in previous 3 weeks
-Bleeding diathesis
-Active bleeding
What are some of the relative CI to Fibrinolysis?
-Transient ischaemic attack in previous 6 months
-Oral anticoagulation
-Pregnancy or first post-partum week
-Non-compressible puncture sites
-Traumatic resuscitation
-Refractory hypertension (systolic BP >180 mmHg)
-Advanced liver disease
-Infective endocarditis
-Active peptic ulcer
What are some of the advantages of thrombolysis in PE?
-Faster improvements in pulmonary obstruction, PAP, and PVR in patients with PE, compared with UFH alone
-The greatest benefit is observed when treatment is initiated within 48 h of symptom onset, but thrombolysis can still be useful in patients who have had symptoms for 6–14 days.
How can severity of PE be defined
- Used to be Massive or submassive depending on haemodynamics
- 2019 guidance suggests risk assessment for high intermediate, low risk using the following indicators of risk:
->Haemodynamic instability - : cardiac arrest, obstructive shock (systolic BP <90 mmHg or vasopressors required to achieve a BP >_90 mmHg despite an adequate filling status, in combination with end-organ hypoperfusion), or persistent hypotension (systolic BP <90 mmHg or a systolic BP drop >_40 mmHg for >15 min, not caused by new-onset arrhythmia, hypovolaemia, or sepsis)
->using clinical scores integrating PE severity and comorbidity, the Pulmonary Embolism Severity Index (PESI)
- looks at variety of factors - age, sex, cancer, chronic pulmonary disease as well as haemodynamics HR, BP, GCS, RR
-scores Class I-V - Class V highest mortality
->RV dysfunction on TTE or CTPA
-> Elevated troponin levels
Discuss Treatment of right ventricular failure in acute high-risk pulmonary embolism?
Volume optimisation
-Cautious volume loading
- Volume loading can over-distend the RV, worsen ventricular interdependence, and reduce
CO2
Vasopressors and inotropes
- Norad - Increases RV inotropy and systemic BP, promotes positive ventricular interactions, and
restores coronary perfusion gradient BUT Excessive vasoconstriction may worsen tissue perfusion
- Dobutamine Increases RV inotropy, lowers filling pressures BUT May aggravate arterial hypotension if used
alone, without a vasopressor; may trigger or aggravate arrhythmias
- Milrinone - Inotrophy with pulmonary vasodilatation but May aggravate arterial hypotension if used
alone
Reduce PVR - hypoxia, hypercarbia, stress, anxiety, acidosis
ECMO
Should Intermediate-risk PE patients receive thrombolysis?
The Pulmonary
Embolism Thrombolysis (PEITHO) trial. Thrombolytic therapy
was associated with a significant reduction in the risk of haemodynamic decompensation or collapse, but this was paralleled by an increased risk of severe extracranial and intracranial bleeding.
How does and IVC filter work? How are they inserted
The aim of vena cava interruption is to mechanically prevent venous
clots from reaching the pulmonary circulation
Most devices in current use are inserted percutaneously and can be retrieved after several weeks or months, or left in place over the long-term, if needed
What are the indications for an IVC?
VTE and absolute contraindication to
anticoagulant treatment, recurrent PE despite adequate anticoagulation, and primary prophylaxis in patients with a high risk of VTE.
Other potential indications for filter placement, including freefloating thrombi, have not been confirmed in patients without contraindications to therapeutic anticoagulation.
What is CTEPH?
Chronic thromboembolic
pulmonary hypertension
CTEPH is a disease caused by the persistent obstruction of pulmonary arteries by organized thrombi, leading to flow redistribution and
secondary remodelling of the pulmonary microvascular bed.
Describe the pathophysiology of a high risk PE?
-PE leads to obstruction and increased RV afterload
- RV dilatation
- TV insufficienty
- Inc RV wall tension
- Inc RV 02 demand
- Myocardial ischaemia
- Dec. RV contractility
- Dec RV output
- Dec LV preload
- Dec CO
- Hypotension red. coronary perfusion
- further dec to RV filling and perfusion
- Further dilatation and LV obstruction
What are some of the strong risk factors for VTe
Fracture of lower limb
Hospitalization for heart failure or atrial fibrillation/flutter
(within previous 3 months)
Hip or knee replacement
Major trauma
Myocardial infarction (within previous 3 months)
Previous VTE
Spinal cord injury
What are some of the Moderate risk factors for VTe?
Arthroscopic knee surgery
Autoimmune diseases
Blood transfusion
Central venous lines
Intravenous catheters and leads
Chemotherapy
Congestive heart failure or respiratory failure
Erythropoiesis-stimulating agents
Hormone replacement therapy (depends on formulation)
In vitro fertilization
Oral contraceptive therapy
Post-partum period
Infection (specifically pneumonia, urinary tract
infection, and HIV)
Inflammatory bowel disease
Cancer (highest risk in metastatic disease)
Paralytic stroke
Superficial vein thromb
What are some of the Weak risk factors for PE
Bed rest >3 days
Diabetes mellitus
Arterial hypertension
Immobility due to sitting (e.g. prolonged car or air travel)
Increasing age
Laparoscopic surgery (e.g. cholecystectomy)
Obesity
Pregnancy
Varicose veins
