B4.030 - CBCL Pulmonary Embolism

Question 1

If you suspect a patient has DVT what should you use in your assessment

Answer 1

Wells criteria

Question 2

If the patient has a low probability for DVT what should you do

Answer 2

Obtain D-dimer to exclude DVT if normal

Question 3

If the patient has a high probability for DVT what should you do

Answer 3

Obtain a lower extremity ultrasound (highly sensitive and specific) to evaluate for presence of a DVT and its site of involvement/thrombus burden if present

Question 4

if you suspect a patient has PE what should you do

Answer 4

Obtain CXR

Question 5

if you suspect a PE and the CXR doesn’t demonstrate an obvious reason for the patient symptoms that would exclude PE

Answer 5

get a CTA of the chest or V/Q lung scan if CTA is contraindicated

Question 6

if a patient has experienced blunt thoracic trauma what should you start with

Answer 6

CXR

Question 7

if a patient has experienced blunt thoracic trauma that was low to moderate and the CXR is normal

Answer 7

It can stop here if nothing concerning on CXR

Question 8

if a patient has experienced blunt thoracic trauma and X ray is positive

Answer 8

procede to CT

Question 9

how should penetrating chest trauma be evaluated

Answer 9

by both CXR and CT

Question 10

what do the green and blue arrow point to

Answer 10

blue - true lumen

green - false lumen

Question 11

what are the yellow arrows pointing to

Answer 11

pericardial effusion

Question 12

what is pictured here

Answer 12

intimal flap dissection involving the ascending and descending thoracic aorta

Question 13

what is a type A aortic dissection

Answer 13

involves ascending aorta

Question 14

what is a type B aortic dissection

Answer 14

involves descending aorta (originating after takeoff of brachiocephalic artery)

Question 15

epidemiology of aortic dissection

Answer 15

peak age 50-65

male>female

Question 16

signs and symptoms of aortic dissection

Answer 16

Tearing/ripping chest pain

back pain

aortic insufficiency

BP difference between arms

Question 17

complications from aortic dissection

Answer 17

cardiac tamponade

carotid involvement

coronary involvement

Question 18

management of type A artic dissection

Answer 18

surgical management

Question 19

type B aortic dissection management

Answer 19

usually medical

consider surgery if organ hypoperfusion or shock

Question 20

if you have a patient (older male with tearing chest pain radiating to the back) what should you do

Answer 20

1. obtain CXR
2. if CXR does not demonstrate an obvious reason for pain it excludes dissection
3. obtain CTA

Question 21

what is this + for

Answer 21

Pulmonary embolism

Question 22

what is this + for

Answer 22

right heart strain sign of hemodynamically significant PE

Question 23

what is an IVC filter

Answer 23

metallic basket placed in IVC to catch emboli from lower body veins

can be placed in patients with DVT to prevetn PE

or
PE with or without DVT

Question 24

what are absolute indications for IVC filter in patients with DVT/PE

Answer 24

contraindication for anticoagulation

recurrent PE in spite of anticoagulation

anticoagulation-related complication

Question 25

what are relative indications for IVC filter

Answer 25

1. free floating thrombus in IVC or iliofemoral segments 2. pE and limited cardiac reserve 3. prophylaxis in pts wiht severe trauma who cant walk 4. prophylaxis for surgery in pts with DVT 5. poor compliance with anticoagulation 6. protection druing DVT

Question 26

where should IVC filters be placed

Answer 26

below renal veins because they dont have collateral flow

Question 27

when do IVC filters come out

Answer 27

when no longer needed

Question 28

IVC filter complications

Answer 28

migration limb fracture IVC rupture Pierce adjacent viscera/aorta IVC thrombiss lead sot increased lower exterminty venous stasis and DVTs

Question 29

what are Wells criteria

Answer 29

Question 30

what does a D Dimer test for in the body

Answer 30

fibrin

Question 31

What imaging study will be the most sensitive and specific in detection of mediastinal hematoma?

Answer 31

CT of chest

Question 32

What is a common presentation for infants with severe aortic coarctation?

Answer 32

Weak femoral pulse and possible cardiac murmur

Question 33

Describe the conditions at the top of the normal upright lung?

Answer 33

At the top of the lung, PAO2 and VA/Q are higher than at the bottom of the lung, while alveolar ventilation and PACO2 are lower than at the bottom of the lung.

Question 34

A 22-year-old woman with previously normal pulmonary function is admitted to the ER at KUMC and now has the following data breathing room air: PaO2 = 85 mm Hg PaCO2 = 43 mm Hg Arterial pH = 7.36 PECO2 = 14 mm Hg Respiratory frequency = 24 breaths / min (normal for this person: 14 / min) Tidal volume 700 ml (normal for this person: 450 ml) These data indicate that this patient has what condition?

Answer 34

Acute Pulmonary Embolism ## Footnote The key variable here is the high VD/VT = (PaCO2 - PECO2) / PaCO2 = 0.6 (normal 0.20 - 0.35). The air coming from the alveolithat are not perfused (because of the embolism) has no CO2 and “dilutes” the PECO2.

Question 35

Aortic dissection is suspected in a 64-year-old male. What is the most appropriate test to confirm the diagnosis?

Answer 35

CTA, MRA, and TEE have similar sensitivity and specificity for evaluation and confirmation of aortic dissection. CTA is usually obtained because fast and cost-efficient. MRA may be used with renal failure or iodine allergy. TEE is user dependent and may take longer to obtain. A chest x-ray is often performed initially in order to rule out other causes of the chest pain, but is not confirmatory for aortic dissection.

Question 36

describe the usefulness of a D dimer

Answer 36

high negative predictive value

Question 37

The American College of Radiology’s (ACR) Appropriateness Criteria take into account a given study’s what 2 features when making a recommendation regarding what particular imaging study should be ordered for a patient?

Answer 37

Safety diagnostif efficacy

Question 38

JJ is a 40-year-old female with history and physical examination findings suspicious for lower extremity DVT. She undergoes a lower extremity ultrasound examination for further evaluation. A typical lower extremity ultrasound examination utilizes how many different tests to evaluate for a DVT?

Answer 38

3 ## Footnote A standard lower extremity ultrasound examination ordered for the evaluation of DVT includes: Venous compression Color Doppler Duplex Doppler

Question 39

what imaging studies is the most accurate for diagnosing a PE?

Answer 39

A chest radiograph can be performed to evaluate for pneumonia or pneumothorax, but a **CTA of the chest is most accurate** for diagnosing PE. If the patient is allergic to IV contrast or has renal insufficiency (placing them at increased risk for renal failure from IV contrast) a V/Q lung scan may be performed.

Question 40

where is the appropriate place to place an IVC filter

Answer 40

B

Question 41

when would be the most appropriate time/setting to schedule a patient to have his/her retrievable IVC filter removed?

Answer 41

**At the time of discharge to home from a rehabilitation facility after recovering from traumatic intracranial hemorrhage.** The IVC should be removed when the hemorrhage has been resolved, and surgery and rehabilitation has been completed.

Question 42

absolute indications for placing an IVC filter

Answer 42

Absolute indications for IVC include: contraindication for anticoagulation (not poor patient compliance), recurrent PE in spite of anticoagulation, and anticoagulation-related complication.

Question 43

KF is a 30-year-old male who presents with right lower extremity pain. He was recently released from the hospital after being admitted for several days for treatment following a motor vehicle accident. What factor places him at greatest risk for a lower extremity DVT?

Answer 43

Obesity, smoking, and varicose veins are minor risk factors for developing DVT. Age is not a significant risk factor for DVT in patients less than 60 years of age. **Recent trauma is a major risk factor for developing DVT.**

Question 44

SH is a 34-year-old-female who presents with a massive PE and evidence of right heart strain. What is the most appropriate next step in the treatment of this patient?

Answer 44

**Emergent catheter-directed thrombolytic therapy/embolectomy.** This is performed in cases where systemic signs of right heart failure are observed.

Question 45

JW is a 58-year-old-male who presents with chest pain. He is diagnosed with a type B aortic dissection. What was his biggest risk factor for developing an aortic dissection?

Answer 45

Hypertension is considered as the most important risk factor for aortic dissection and is present in about 80% of patients with aortic dissection.