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R9 > Chapter 151 - Pulmonary embolism > Flashcards

Chapter 151 - Pulmonary embolism Flashcards

1
Q

Mortality of acute PE

A

10% 3 months

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2
Q

Consequences of PE

A

1) hypoxemic vasoconstriction 2) increase pulmonary resistance 3) increase right ventricular afterload 4) RV hypokinesis and dilation 5) tricuspid regurtication 6) RV failure 7) decrease CO

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3
Q

Non-resolved thromboemboli in PE

A

fibrotic deposits –> chronic pulmonary hypertension and RV dysfunction

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4
Q

Symptoms of PE

A

1) dyspnea 2) chest pain (pleural irritation from pulm infarction) 3) hemoptysis

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5
Q

Signs of PE

A

1) tachypnea 2) tachycardia 3) rales 4) decreased breath sounds 5) jugular venous distension 6) fever 7) hypotension <10%

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6
Q

Clinical impression of PE sensitivity and specificity

A

85% sen, 51% spe

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7
Q

Lab test for PE

A

1) leukocytosis 2) elevated LDH 3) elevated AST 4) elevated CRP/ESR

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8
Q

D dimer level that excludes PE

A

< 500 mg/L age X 10 mg/L older than 50 excludes only if also low clinical suspicion

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9
Q

Biomarker for RV dysfunction

A

1) troponin (0.1 ng/ml TnT; 0.4 ng/ml TnI) 2) BNP (90 pg/ml) 3) NT-proBNP (600 pg/ml)

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10
Q

S1Q3T3 explained

A

prominent S wave in lead 1 Q wave and inverted T wave in lead 3 sign of acute RV overload (cor pulmonale) reflecting strain

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11
Q

Fleischner sign

A

Enlarged pulmonary artery on CXR

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12
Q

Hampton hump

A

Peripheral wedge of airspace opacity showing lung infarction on CXR

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13
Q

Westermarck sign

A

Regional oligemia on CXR

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14
Q

Knuckle sign

A

Abrupt tapering or cutoff of pulmonary artery

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15
Q

PIOPED (Prospective investigation of pulmonary embolism diagnosis) II trial on CTPA sen and spe

A

83% sen; 96% spe

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16
Q

RV dysfunction on CTPA

A

Right to left ventricular end diastolic dimentional ratio > 0.9

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17
Q

Right heart strain increases death with PE by

A

2x

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18
Q

TAPSE (tricuspid annular plane systolic excursion)

A

quantitative echo parameter least user dependent most reproducible = 1.6 cm is intermediate risk

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19
Q

McConnell sign

A

depressed contractility of RV free wall compared with RV apex

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20
Q

Thrombus in transit

A

thrombus inside the RV rare finding

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21
Q

Rate of LE DVT in PE

A

30-50%

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22
Q

PE with confirmed DVT have this much increased mortality

A

2x

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23
Q

Ventilation/perfusion scan in PE uses

A

Only if CTPA contraindicated sensitive but non-specific

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24
Q

Wells score for PE

A

TABLE 151.1

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25
Q

Revised Geneva score for PE

A

TABLE 151.1

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26
Q

Diagnostic algorithm for PE

A

FIGURE 151.2

27
Q

Definition of low risk PE and associated mortality

A

1) normotensive 2) no RV dysfunction 3) no elevated cardiac biomarker 40% of all cases are low risk mortality <2%

28
Q

Definition of intermediate risk PE and associated mortality

A

1) normotensive 2) RV dysfunction OR 3) elevated cardiac biomarker 55% of all PE are this group mortality 3-15%

29
Q

Definition of high risk PE and associated mortality

A

1) hemodynamically unstable SBP < 90 or cardiac arrest 5% of all PE Mortality 15-30% >60% if need CPR

30
Q

European society of cardiology: intermediate low vs intermediate high risk PE

A

Intermediate low = RV dysfunction only intermediate high = RV dysfunction with positive biomarker (trop or BNP/pro-BNP)

31
Q

Pulmonary embolism severity index (PESI)

A

TABLE 151.2 PESI III to V - mortality 30 day 24.5% PESI simplified >/= 1 = mortality 11%

32
Q

Heart-type fatty acid binding protein (HFAB)

A

> 6 mcg/lt is marker for intermediate risk PE

33
Q

Marker of non-low risk PE on echo

A

1) RV/LV EDD > 1 2) TAPSE < 1.6 cm 3) TRJV (jet velocity) > 2.6 m/s 4) estimated RV SBP < 52 mmHg 5) McConnell sign 6) IVC collapsibility > 50% 7) RV hypokinesia 8) left shift of interventricular septum

34
Q

Goal of treating PE

A

1) prevent mortality 2) prevent late-onset chronic thromboembolic pulmonary HTN

35
Q

Initial supportive therapy of PE

A

1) ABC 2) oxygen to keep sat > 90 3) IV fluid small volume bolus 4) norepinephrine - less likely to cause tachy 5) anticoagulation

36
Q

Indication for IVC filter

A

1) contraindication to anticoagulation 2) PE despite adequate anticoagulation 3) unclear if benefit in severe PE with hemodynamic instability as a combined effect with anticoag

37
Q

Thrombolysis in PE key points

A

1) greatest benefit in 48 hr 2) still benefit in 14 days 3) high risk patients; maybe intermediate (controversial) 4) standard route is IV via peripheral line but catheter gaining popularity

38
Q

Regimen for systemic thrombolysis in PE

A

1) 100 mg alteplase over 2 hrs 2) hold heparin during thrombolysis 3) reteplase and desmoteplase also can be used

39
Q

Mortality benefit in high risk PE with systemic thrombolysis

A

1) all cause mortality 47% to 15% 2) PE related mortality 42% to 8.4%

40
Q

Risk of major bleeding with thrombolysis in PE

A

1) 9.24 vs 3.42% 2) higher intracranial bleed 3) major risk pt age > 65

41
Q

ULTIMA trial key points

A

1) RCT ultrasound assisted CDT vs anticoag 2) RV function improved faster 3) bleeding 3.5%

42
Q

Catheter directed thrombolysis complications

A

1) bleed 2) contrast-induced nephropathy 3) device complications 4) access problems 5) heart and lung injuries still less than systemic thrombolysis

43
Q

Dose of tpa in CDT in PE

A

15-25mg

44
Q

Treatment endpoint of CDT in PE

A

1) high risk then hemodynamic stability 2) intermediate risk then clinical improvement, improved pulmonary artery pressure or right heart strain 3) complete clot removal should not be endpoint

45
Q

Angiojet rheolytic thrombectomy system in PE

A

black box FDA warning with increased adverse events and death

46
Q

Vortex AngioVac aspiration system

A

1) extracorporeal bypass circuit 2) drainage filtration and reinfusion of blood cleared from clot 3) 26F delivery sheath from IJ or femoral needed 4) no lytics needed

47
Q

Surgical thrombectomy in PE steps

A

1) median sternotomy with cardiopulmonary bypass 2) pulmonary artery opened the material extracted 3) right atrium + ventricle explored for possible thrombi 4) close foramen ovale

48
Q

Surgical thrombectomy in PE indication

A

1) refractory shock with contraindication or failed lytic

49
Q

Mortality of surgical thrombectomy in PE

A

10-30%

50
Q

Conditions for early discharge after PE

A

1) low risk PE from PESI score 2) normal hemodynamic 3) no oxygen 4) no bleeding risk factors 5) no serious comorbid conditions 6) mental capacity to consent 7) has social support if deteriorate 8) absence of symptomatci DVT

51
Q

PE suspicion algorithm

A

FIGURE 151.7

52
Q

Incidental subsegmental PE treatment

A

1) anticoagulate 2) hold if high risk of bleeding

53
Q

Thrombus in transit mortality

A

40%

54
Q

Pregnancy PE

A

1) LMWH adjusted dose 2) lytics can be used in pregnancy with similar risk to non-pregnant population

55
Q

Non-thrombotic pulmonary embolism types

A

1) adipocytes 2) amniotic cells 3) tumor cells 4) bacteria/fungi 5) gas 6) foreign material

56
Q

Triad of fat embolism

A

1) pulmonary (respiratory distress) 2) central nervous system (altered mental status) 3) skin (petechial rash)

57
Q

Triad of amniotic fluid embolism

A

1) sudden hypoxia 2) hypotension 3) coagulopathy

58
Q

Air embolism lethal volume

A

100-500 ml

59
Q

Treatment of air embolism

A

Place patient in left lateral decubitus to prevent RV outflow obstruction by airlock

60
Q

Risk of recurrent PE at 1, 5 10 years

A

13% 1 year 23% 5 year 30% 10 years

61
Q

CTEPH definition

A

Mean pulmonary-artery pressure > 25 mmHg for 6 months after PE

62
Q

CTEPH symptoms

A

1) dyspnea 2) fatigue 3) exercise intolerace

63
Q

Rate of CTEPH after PE

A

2-4% usually within 2 years

R9 (200 decks)

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