40 - Pulmonary Embolism Flashcards
What is Virchow’s triad?
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Describes the three broad categories of factors that are thought to contribute to thrombosis
- Hypercoagulability
- Venous stasis
- Endothelial damage
What are the two categories of risk factors that fall under hypercoagulability?
- Hereditary deficiencies
- Acquired
What are hereditary deficiencies that lead to hypercoagulability?
- Antithrombin
- Protein C or S Deficiency
- Factor V Leiden
- Prothrombin gene mutation
- Dysfribrinogenemia
What are the acquired conditions that lead to hypercoagulability?
- Cancer
- Pregnancy & postpartum period
- Oral contraceptives
- Hormone replacement therapy
- Polycythemia vera
- Smoking
- Antiphospholipid Antibody
- Chemotherapy
What are the conditions that lead to venous stasis?
- Immobility (cast, long travel, bed rest, etc.)
- Advanced age
- Acute medical illness
- Major surgery
- Spinal cord injury
- Obesity
What are the conditions that lead to endothelial damage?
- Major surgery
- Trauma
- Central venous catheterization
What are the most common clinical symptoms of a PE?
Tachypnea (92%) Chest or Pleuritic pain (85%) Dyspnea (84%) Anxiety (59%) Cough (53%) Tachycardia
What are later manifestations of PE?
Hemoptysis Low-grade fever Wheezing, rales Loud pulmonic component of the 2nd heart sound Right-sided S3 or S4 Right ventricular lift or heave
What are two risk prediction scoring systems you can use?
- Wells criteria
- Revised Geneva score
Wells is more common
What factors does the Wells criteria take into consideration?
- Suspect DVT
- Alternative diagnosis is less likely
- High heart rate
- Immobilization
- History of DVT
- Hemoptysis
- Malignancy w/ treatment
What diagnostic tests can you run?
- Arterial blood gas
- D-dimer
- Troponin
- ECG
- Chest x-ray
- CT angiography***
- Ventilation-perfusion scan
- Lower extremity testing for DVT
- Pulmonary arteriography***
What is the primary method of diagnosing a PE?
CT angiography
- Need to give bolus of dye
- Patient needs
What is the gold standard for diagnosing PE?
Pulmonary arteriography
- Used when CT angiography is inconclusive
- More invasive
How do you decide what treatment options are best for a patient with a diagnosed PE?
- First stabilize the patient
- Then assess whether or not the patient is hemodynamically stable
How do you treat a hemodynamically stable patient?
Anticoagulation
- Anticoagulation w/ unfractionated heparin, Subcutaneous low-molecular-weight-heparin, or fondaparinux
- Warfarin should be started at the same time
- New thrombin inhibitors & factor Xa inhibitor riboroxaban are now approved for the tx of PE
