PE, DVT, Pneumothorax

Question 1

Fat embolus

Answer 1

Long bone fx

Liposuction

Question 2

Amniotic fluid embolus

Answer 2

DIC postpartum

Question 3

Air embolus

Answer 3

Caisson dz – “the bends”
IV
Trauma – too much pressure from ventilator

Question 4

Bacterial embolus

Answer 4

Bacterial endocarditis

Question 5

Pneumothorax

Answer 5

Abnormal collection of air in pleural space separates lung from chest wall

Primary spontaneous: randomly occurs
-tall, thin, young males
d/t rupture of apical blebs

secondary – existing lung pathology – more severe

Sx: SOB, CP

Dx: physical exam, CXR, CT scan

Question 6

Tension pneumothorax

Answer 6

One way valve mechanism
Builds up pressure

Shift organs towards normal side – displacement of trachea

Leads to airway/vascular compromise

Tx: needle decompression

Question 7

Virchow’s triad

Answer 7

Stasis: severely ill, paralyzed, long trips, cast

Hypercoagulability: sickle cell, polycythemia, estrogen excess, cancer, pregnancy, OCPs, smoking

Endothelial damage: vessel trauma, fracture, foreign body, bacterial infection

Question 8

Deep venous thrombosis (DVT)

Answer 8

Sx: foot/ankle (u/l) edema +/- pain +/- Homan’s sign (pain w/ ankle dorsiflexion) +/- palpable cord

Dx: compression US – high probability
D-dimer then US – low probability (R/O test)

Prevention:
Heparin (sq), enoxaparin (LMW), compression stockings or sequential compression devices (SCDs)

Tx:
Initial first 10 days: LMW heparin, fondaparinux, unfractionated heparin
-Factor Xa inhibitors, direct thrombin inhibitors

Long term anticoagulation: warfarin (INR 2-3), LMW heparin, fondaparinux

Question 9

Pulmonary embolism

Answer 9

Sx: pleuritic CP, SOB, cough, hemoptysis (rare), fever, tachypnea, tachycardia, altered mental status/confusion

R/o test: elevated D-dimer +/- DVT on lower extremity US, usually normal CXR
Large A-a gradient on arterial blood gas
+/- ECG changes (S1Q3T3 – deep S in I, large Q and inverted T in 3)
CT scan with contrast most often used
V/Q scan
Pulmonary angiogram

“saddle embolus” = death

Tx:
Massive PE: thrombolysis immediately – usually just heparin/warfarin

First 10 days: LMW heparin, fondaparinux, unfractionated heparin

Long term anticoagulation: Warfarin (INR 2-3)
Factor Xa inhibitors: rivoroxaban, apixaban, endoxaban
Direct thrombin inhibitor – dabigatran