Pulmonary Embolism

Question 1

What is the gold standard to diagnose a PE?

Answer 1

Pulmonary Angiography

Obtained via percutaneous catheterization (via Femoral vein)

Question 2

What is the preferred initial diagnostic study for a PE, even though it is not the Gold Standard?

Answer 2

Helical CT Scan

Question 3

What S/Sx might present clinically with a PT suspected of PE?

Answer 3

Dyspnea
PLEURITIC CHEST PX
Hemoptysis
Inc HR, Inc RR
Orthopnea
Calf Swelling/Px
Rales/Wheezing
4th Heart sound
FACTOR V LEIDEN DEFICIENCY

Question 4

Doppler U/S is sensitive for what kinds of PEs?

Answer 4

PE’s above the knee

Question 5

A massive PE is marked by what clinical criteria?

Answer 5

Systolic BP <90mmHg
Drop in Systolic BP of >40mmHg
JVD or HYPOtension

Question 6

What clinical studies or labs might you order to determine if your PT has a PE?

Answer 6

D-Dimer to r/o PE
ABG (Marked by RESP ALKALOSIS and HYPOXEMIA)
CBC
CMP (lytes for hyponatremia) eGFR to see if contrast will be okay for CT
Troponin and BNP to r/o CHF or MI

Question 7

Which PE’s are the most fatal?

Answer 7

Axillary or subclavian in origin (can also be pelvic)

Thrombi which form around a catheter

Question 8

What two DAOAC’s can be utilized as a monotherapy?

What is a contraindication to DAOACs for PE Tx?

Answer 8

Rivaroxaban (Xarelto)
Apixaban (Eliquis)

IF PT IS HEMODYNAMICALLY UNSTABLE; DAOACs ARE NOT RECOMMENDED; use FIBRINOLYTIC AGENTS (urokinase or tPa(alteplase))

Question 9

What anticoagulant therapy is CI in pregnancy?

Answer 9

Warfarin (Coumadin)

Question 10

If you are going to Rx a PT Warfarin(Coumadin) what must you consider…

Answer 10

Bridging gap with LMWH for 4 to 5 days

Question 11

Fibrinolytics may be indicated in what case?

What are two examples?

Answer 11

Massive PE or cor pulmonale
HEMODYNAMIC INSTABILITY

Urokinase
tPa (Tissue Plasminogen Activator) Alteplase

Question 12

If anticoagulative therapies are CI what therapy would you Rx a PT either at extreme risk or with a PE?

Answer 12

Vena cava filter

Question 13

What is the therapeutic PTT desired for LMWH (Lovenox)?

Answer 13

1.5 to 2x control w/in 24hrs

Monitor platelets (do not want thrombocytopenia)

Question 14

What imaging studies would you order for a PT with a suspected DVT?

Answer 14

Contrast venography: GOLD STANDARD

Doppler U/S: (False + w/ CHF, ascites, and prior DVT) Misses calf vein DVTs

Question 15

PTs who survive an acute PE are at greater risk for what 3 key clinical conditions?

Answer 15

Recurrent PE
Pulmonary HTN
Cor Pulmonale (70% of PTs)