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CVPR > CVPR Week 6: Pulmonary embolism > Flashcards

CVPR Week 6: Pulmonary embolism Flashcards

(70 cards)

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1
Q

Objectives

A
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2
Q

Pulmonary embolism description

A
  • usually refers to a blood clot which has migrated from the leg to the lung
  • but can also originate from the upper extremity, pelvis or the abdominal cavity
  • Also
  • embolisms of air, amniotic fluid,, tumor and fat can cause similar symptoms but are much less common
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3
Q

Pulmonary embolism prevalence

A
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4
Q

Clinical manifestations of Pulmonary embolism

7 listed

A
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5
Q

Diagnostic testing in Pulmonary embolism

6 listed

A
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6
Q

CT angiogram of pulmonary arteries description

A
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7
Q

CT angiogram of pulmonary arteries measures?

A

RV dilation and specifically

RV/LV ratio and an

RV/LV > 1 is associated with RV strain and an increased risk of death

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8
Q

RV/LV ratio

A

RV/LV > 1 is associated with RV strain and an increased risk of death

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9
Q

Positive study of CT angiogram of pulmonary arteries

A

in a positive study, filling defects are seen within the pulmonary arteries

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10
Q

What does a CT angiogram look like?

A
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11
Q

What does an RV/LV ratio > 1 look like?

A
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12
Q

Ventilation-Perfusion scanning

A
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13
Q

VQ scan AKA

A

Ventilation-Perfusion scanning

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14
Q

VQ scan mechanism

A

A nuclear medicine test where radiolabled xenon is inhaled while Technectium-99 labeled colloid is injected into the venous system

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15
Q

VQ scan for PE

A

Areas in the lung which have perfusion defects without ventilation defects suggest PE

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16
Q

VQ scan sensitivity and specificity

A

Much less specific and sensitive than the CT angiogram

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17
Q

VQ scan clinical use

A

usually reserved for patients with renal failure or to diagnose chronic PE

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18
Q

VQ test results which are non-diagnostic of PE

A

can indicate normal perfusion which essentially rules out PE

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19
Q

VQ test results suggesting PE

A

Diffusion defect is suggestive of PE

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20
Q

Multiple perfusion defects

A
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21
Q

Lower Extremity Doppler for DVT

A
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22
Q

Case: Does this patient have risk factors for PE?

A
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23
Q

Classic risk factors for PE

3 listed

A

Virchow’s Triad

  1. Hypercoaguability
  2. Stasis
  3. Endothelial damage
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24
Q

Risk factors for PE

A
  • Factor V ledien
  • Prothrombin gene mutations
  • Protein C and S deficiencies
  • Antithrombin III deficiencies
  • Cancer
  • Surgeries (Particularly orthopedic)
  • Neurosurgeries
  • Pregnancy
  • immobilization
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25
Question What diagnostic test for this patient?
in this case VQ scan because of the renal insufficiency!!
26
why not a D-dimer?
27
What is a D-dimer?
a quantitative measure of degraded crosslinked fibrin in the blood associated with blood clot formation
28
Why isn't D-dimer very diagnostic of PE?
* Because it can be elevated in patients post-surgery, pneumonia, CHF, cirrhosis, cancer and HIV * also it is not recommended in hospitalized patients
29
How can a D-dimer be used for PE?
In patients with a low to moderate suspicion of PE d-dimer has a negative predictive value of 98%
30
D-dimer for high clinical suspicion of PE
negative predictive value is only 70%
31
How to determine the probability of PE
* Modified Well's Criteria * Geneva Scoring System
32
Clinical predictions for PE
33
Modified Well's Score
34
Case Modified Wells Score
35
Geneva scoring system for PE
36
Case VQ scan
37
Case How do we treat our patient?
38
Patient suddenly deteriorates How do we treat his shock?
39
Treatment of massive pulmonary embolism: patients in shock
40
TPA AKA
Tissue Plasminogen activator (T-PA)
41
EKOS Catheter AKA
Catheter-directed thrombolysis
42
ECMO AKA
Extracorporeal membrane oxygenation
43
ECMO for PE
May be an option for patients who are severely unstable
44
Treatment option for PE for patients who are severely unstable
ECMO
45
EKOS catheter clinical use
can be useful particularly in patients with high-risk of bleeding
46
PE treatment for patients who are at a high-risk for bleeding
EKOS
47
Massive PE treatment for patients in shock
Thrombolytics (tissue plasminogen activator (T-PA) is the standard of care
48
Patient improves but returns a week later with hematemesis
49
Inferior vena caval filters clinical use
* Lower extremity DVT or PE in patients with contraindications to anticoagulation * Patients with PE who have a recurrence while on anticoagulation * certain patients with severe pHTN and PE
50
Inferior vena caval filters
51
Long-term anticoagulation options for PE 5 listed
* Warfarin * Low molecular weight heparin * Oral factor Xa inhibitors * Direct thrombin initiator (dabigatran) * Direct oral anticoagulants
52
Warfarin AKA
Coumadin
53
Warfarin considerations for PE
* needs monitoring and is somewhat difficult to control * easily reversible
54
Low molecular weight heparin considerations for PE
Particularly in cancer patients
55
Oral factor Xa inhibitors for PE
Rivaroxaban or apixaban
56
Direct thrombin inhibitor for PE
Dabigatran
57
Dabigatran is a?
Direct thrombin inhibitor
58
Rivaroxaban or apixaban are?
Oral factor Xa inhibitors
59
Symptoms of PE
Symptoms of PE are somewhat non-specific a high-index of suspicion is needed to make the Dx
60
Preferred diagnostic method for PE
CT Angiogram it may also provide other clues/causes to the patient's symptoms
61
VQ scan and venous dopplers are reserved for patients with?
contraindications to CT scan such as renal insufficiency
62
contraindications to CT angiogram
renal insufficiency
63
PE diagnosis with renal insufficiency or contraindications to CT scan
VQ scan and venous dopplers
64
How is d-dimer used for PE?
useful only in patients with low clinical suspicion to rule out
65
PE Treatment first-line therapies
* low molecular weight heparin * oral factor Xa inhibitors * IV unfractionated heparin
66
Treatment of PE in shock
Thrombolytics (tissue plasminogen activator-TPA) are reserved for patients in shock
67
TPA for treating PE
Reserved for patients in shock
68
Warfarin MOA
Vitamin K antagonist
69
Long-term treatment options for PE
* Warfarin * Factor Xa inhibitors * Direct thrombin inhibitors
70
Direct oral anticoagulant reversibility?
Direct oral anticoagulants are not readily reversible

CVPR (93 decks)

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