PE Flashcards
1
Q
What is the years Items
A
- Pe is more likely diagnosis
- Unilateral LL edema
- hemoptysis
Any positive consider positive
2
Q
Wells score Cut off
A
More than 3
3
Q
Geneva score
A
More than 4
4
Q
D -Dimer
A
Normal D-dimer in Low pre-test probability has
100% NPV In patient with high clinical probability, D-Dimer is not
helpful
5
Q
D -Dimer
A
Normal D-dimer in Low pre-test probability has
100% NPV In patient with high clinical probability, D-Dimer is not
helpful
6
Q
D-Dimer for Age
A
Age * 10 if more than 50 years
7
Q
Diagnositc criteria
A
1- CT pulmonary angio
2- V/Q scan
3- Echo in unstable pt
8
Q
V/Q scan moditlites in PE ?
A
1- IF Normal negative PE
2 - If V/Q scan yields high probability for PE ( diagnostic )
3- If non diagnostic should be wiht US in PT with Low probability
IF high need further investigation
9
Q
Chest xray in PE
A
1- Westermark sign
2- Hampton sign
10
Q
High probability of PE CT PE cant be done ? Next step
A
CUS for Proximal DVT if positive no need to go further
If negative further testingneed to be done :-
V/Q scan
IF positive :- no need to go further
11
Q
CUS postive3 for PE and used to diagnosis of PE in high probability pt what is the next ?
A
Need to assess pe severity
12
Q
ECG finding in PE
A
1- S1 Q3 T3
13
Q
D-Dimer :-
A
Good -ve and poor +Ve
Sane as clinical scores
14
Q
Low and intermediate clincial probability’s , next step
A
D-Dimer
15
Q
Unstable pt , with high probability of PE , Next step
A
ECHO
16
Q
PE ruled out criteria (PERC )
A
Age more than 70
Hr moretha 100
Spo2 less than 95
One leg swelling
Hemoptysis
Previuse DVT or PE
Hormone use
Surgery or trauma within last 4 wks
17
Q
Classification of PE pt
High risk :-
A
- hemodynamic unstebality
- PESI score more than or equal one
- PESI class 3-5
- RV dysfunction
- elevated trop T
18
Q
Intermediate high risk pt
A
Have postive in PESI score and
RV dysfunction
And Trop T elevated
(Except low BP )
19
Q
Intermediate high risk pt
A
Have postive in PESI score and
RV dysfunction
And Trop T elevated
(Except low BP )
20
Q
Intermediate Low
A
PESI score more than or equal one
RV dysfunction OR trop T
21
Q
Trop T positive and RV dysfunction what is the risk calcification
A
Intermediate high
22
Q
PESI score
A
- more than 80
- Cancer
- cardio- pulmonary disease
- Hr more than 110
- BP :- less than 100
- SPo2 :- less than 90
23
Q
Low risk what is the next step ? In mangment
A
NAOC
24
Q
Intermediate Risk next step in management
A
LMWH
25
Intermediate high in mangment like high risk
True ( need to be reviewed )
26
Medication during intubation ?
Ketamine and etomidate
27
PE in respiratory distress , Next step
Start with conventional devices
Avoid intubation if possible
28
Ventilation setting in PE
Low TV
- low or zero PEEP
- Plateau less than 30
29
Vasopressors in PE
1- NE
Seconde line
Dobutamine
30
When we have to consider ECMO
1- Arrest
2- Bridge to other therapies
31
IVC filter ? Indication
1- contraindication of coagualtion
2- PE in adequate anticoag
32
PEITHO trail
Thromplolysis improved CVS decompansastion in intermediate risk pt but increase the risk of major hemorrhage and stroke
33
PE algorithm
Suspected pt :-
1- rule out criteria
2- clinical scores
3- ( D-Dimer or CT PA based on PE probability
4- anticoagulant
5- risk stratification
6- Low risk NAOC
7- high risk :- reperfusion
8- intermediate :-
High :- LMWH and monitor consider reperfusion therapy if deteriorate
Low :- LMWH
34
Discharge of pt with low risk
1- if no other reasons of hospitalization
2- family and social support
3- easy access to medical care
Then discharge if one of them is no then admit
35
Thrompolysis
Molecule Recombinant tissue-type plasminogen
activator (rtPA)
Streptokinase
Regimen
100 mg over 2 h 0.6 mg kg over 15 min
(maximum dose 50 mg) 250,000 IU as a loading dose over 30 min,
followed by 100,000 IU/hover
12-24 h
Accelerated regimen: 1.5 million
IU over 2 h
Contraindications to fibrinolysis
Absolute • History of haemorrhagic stroke or stroke of
unknown origin
• Ischaemic stroke in previous 6 months
• Central nervous system neoplasm • Major trauma, surgery, or head injury in
previous 3 weeks
• Bleeding diathesis
• Active bleeding
36
Timing of TPA
Greatest benefit when initiated within 48 hrs
Can be still used for 6-14 days
37
Failed of thrombolysis
Prevelance 8-10 %
Next step
:- repeat
## surgical embolectomey :- I
38
ategorization of risk factors for venous thromboembolism based on the risk of
recurrence over the long-term
In PIC
39
Risk Assessment
1- RV by image or lab even in low PESI or a PESI of 0
40
In refractory circulatory collapse or cardiac arrest.
ECMO may be considered, in combination with surgical embolectomy or catheter-directed treatment,
41
PE with No risk factor / duration of therapy
Extended anticoagulation should be considered for patients with no identifiable risk factor for the index PE event.
42
Extended anticoagulation :-
1- pt wiht PE and no risk factor
2- in persistent risk factor other than antiphospholipid
3- in minor reversible risk factors
43
A reduced dose of apixaban or rivaroxaban should be considered after the first 6 months.
44
Cancer pt / pe management
Edoxaban or rivaroxaban should be considered as an alternative to LMWH,
with the exception of patients with gastrointestinal cancer.
45
Pregnant with Low BP , respiratory failure / DIC
Amniotic fluid embolism should be considered in a pregnant or post-partum woman, with unexplained haemodynamic instability or respiratory deterioration, and disseminated intravascular coagulation.
46
Pregnant and high risk PE
Management
Thrombolysis or surgical embolectomy should be considered for pregnant women with high-risk PE.
47
NOACs are not recommended during pregnancy or lactation.
48
Post-PE care and long-term sequelae
Routine clinical evaluation is recommended 3- 6 months after acute PE.
An integrated model of care is recommended after acute PE to ensure optimal transition from hospital to ambulatory care.
It is recommended that symptomatic patients with mismatched perfusion defects on a V/Q scan >3 months after acute PE are referred to a pulmonary hypertension/CTEPH expert centre, taking into account the results of echocardiography, natriuretic peptide, and/or cardiopulmonary exercise testing.
49
PE pt in follow up
After # month
We have to rule out CTEPH
V/q If mismatch present after 3 Month
Then refer pt for pulmonary hypertension / ECHO
50
Definition of hemodynamic instability
1- cardiac arrest
2- obstructive shock :-
SBP less than 90
Or
Vassopresor to keep SBP more than or equal 90
AND :-
END organ hypo perfusion
( Low MS , cold clammy skin , oliguria , increase in lactic acid
3- persistent hypotension
SBp less than 90 OR
More than or equal to 40 drop in SBP
Lasting more than 15 mints
And not caused by new onset arrhythmia
Hypovaemia
Sepsis
One of them
51
V/Q SPECT can be used for PE diagnosis
52
CTPA radiation issues
Significant radiation exposure to young female breast tissue
53
V/Q scintigraphy
It is recommended to reject the diagnosis of PE (without further testing) if the perfusion lung scan is normal.75,122,134,174
I
A
It should be considered to accept that the diagnosis of PE (without further testing) if the V/Q scan yields high probability for PE.134
IIa
B
A non-diagnostic V/Q scan should be considered as exclusion of PE when combined with a negative proximal CUS in patients with low clinical probability, or who are PE-unlikely
54
Further imaging tests to confirm PE may be considered in cases of isolated subsegmental filling defects
55
Initiation of anticoagulation is recommended without delay in patients with high or intermediate clinical probability of PE while diagnostic workup is in progress.
56
High risk pt anticoagulation
It is recommended that i.v. anticoagulation with UFH, including a weight-adjusted bolus injection, be initiated without delay in patients with suspected high-risk PE.
57
PESI SCORE MORE THAN or E 1
! 1 point(s) = 30
day mortality risk
10.9%
58
Treatment of right ventricular failure in acute high-risk pulmonary embolism :-
Pic
59
Fluid In RV management :-
1- less than or E :- 500 cc of RL over 15-30 in CV :- low or normal pressure
60
Fluid In RV management :-
1- less than or E :- 500 cc of RL over 15-30 in CV :- low or normal pressure
61
NE
Increases RV inotropy and systemic BP, promotes positive ventricular interactions, and restores coronary perfusion gradient
62
NE - side effect
Excessive vasoconstriction may worsen tissue perfusion
63
Dobutamine
May aggravate arterial hypotension if used alone, without a vasopressor; may trigger or aggravate arrhythmias
64
ECMO side effect
Complications with use over longer periods (>5À10 days), including bleeding and infections; no clinical benefit unless combined with surgical embolectomy; requires an experienced team
65
High risk pt first step
UFH
66
Percutaneous catheter-directed treatment should be considered for patients with highrisk PE, in whom thrombolysis is contraindicated or has failed
67
ECMO may be considered, in combination with surgical embolectomy or catheter-directed treatment, in patients with PE and refractory circulatory collapse or cardiac arrest
68
Intermediate Risk anticoagulation
If anticoagulation is initiated parenterally, LMWH or fondaparinux is recommended
69
Intermediate Risk anticoagulation
If anticoagulation is initiated parenterally, LMWH or fondaparinux is recommended
70
Warfarin management :-
When patients are treated with a VKA, overlapping with parenteral anticoagulation is recommended until an INR of 2.5 (range 2 — 3) is reached.
71
NOACs are not recommended in patients with severe renal impairment, d during pregnancy and lactation, and in patients with antiphospholipid antibody syndrome
72
Routine use of primary systemic thrombolysis is not recommended in patients with intermediate- or low-risk PE
73
For patients with first PE/VTE secondary to a major transient/reversible risk factor, discontinuation of therapeutic oral anticoagulation is recommended after 3 months.
74
If extended oral anticoagulation is decided after PE in a patient without cancer, a reduced dose of the NOACs apixaban (2.5 mg b.i.d.) or rivaroxaban (10 mg o.d.) should be considered after 6 months of therapeutic anticoagulation.
75
In patients who refuse to take or are unable to tolerate any form of oral anticoagulants, aspirin or sulodexide may be considered for extended VTE prophylaxis
76
In patients who receive extended anticoagulation, it is recommended that their drug tolerance and adherence, hepatic and renal ffunction, and bleeding risk be reassessed at regular intervals.
77
For patients with PE and cancer, weight-adjusted subcutaneous LMWH should be considered for the first 6 months over VKAs.
78
Edoxaban should be considered as an alternative to weight-adjusted subcutaneous LMWH in patients without gastrointestinal cancer
79
Rivaroxaban should be considered as an alternative to weight-adjusted subcutaneous LMWH in patients without gastrointestinal cancer
80
In patients with cancer, management of incidental PE in the same manner as symptomatic PE should be considered, if it involves segmental or more proximal branches, multiple subsegmental vessels, or a single subsegmental vessel in association with proven DVT.376,377
81
Cancer pt GI :-
LMWH
82
Pregnancy and PE
Risk factor increase the risk of PE
including in vitro fertilization: in a cross-sectional study derived from a Swedish registry, the HR for VTE following in vitro fertilization was 1.77 (95% CI 1.41À2.23) overall and 4.22 (95% CI 2.46À7.20) during the first trimester. 382 Other important and common risk factors include prior VTE, obesity, medical comorbidities, stillbirth, pre-eclampsia, post-partum haemorrhage, and caesarean section; documented risk assessment is therefore essential.
83
Pregnancy and PE
Risk factor increase the risk of PE
including in vitro fertilization: in a cross-sectional study derived from a Swedish registry, the HR for VTE following in vitro fertilization was 1.77 (95% CI 1.41À2.23) overall and 4.22 (95% CI 2.46À7.20) during the first trimester. 382 Other important and common risk factors include prior VTE, obesity, medical comorbidities, stillbirth, pre-eclampsia, post-partum haemorrhage, and caesarean section; documented risk assessment is therefore essential.
84
Diagnosis of pulmonary embolism in pregnancy
prevalence of confirmed PE is low among women investigated for the disease, between 2 and 7%.
85
PE in pregnancy
High pre test
D- Dimer + in intermediate low risk Next step :-
1- LMWH
2 - CXR / US .
US +Ve NExt step :- treat and assess risl of severity and early death
IF not :-
V/q if chest xray normal or CTPA
IF chest xray ubnormal :- CTPA
86
PE in pregnancy
Treatment of choice
LMWH is the treatment of choice for PE during pregnancy. 384 In contrast to VKAs and NOACs, LMWH does not cross the placenta, and consequently does not confer a risk of foetal haemorrhage or teratogenicity. Moreover, while UFH is also safe in pregnancy, LMWH has more predictable pharmacokinetics and a more favourable risk profile.
87
PE and pregnancy
Perfusion scintigraphy or CTPA (with a low-radiation dose protocol) should be considered to rule out suspected PE in pregnant women; CTPA should be considered as the first-line option if the chest X-ray is abnormal.385,386
88
A therapeutic, fixed dose of LMWH based on early pregnancy body weight is the recommended therapy for PE in the majority of pregnant women without haemodynamic instability
89
High risk in pregnancy
Thrombolysis or surgical embolectomy should be considered for pregnant women with highrisk PE.4
90
Epidural and PE
Insertion of a spinal or epidural needle is not recommended, unless >_24 h have passed since the last therapeutic dose of LMWH.
Administration of LMWH is not recommended within 4 h of removal of an epidural catheter
91
Risk factors and predisposing conditions for chronic thromboembolic pulmonary hypertension44
1- Findings related to the acute PE event (obtained at PE diagnosis)
Previous episodes of PE or DVT
Large pulmonary arterial thrombi on CTPA
Echocardiographic signs of PH/RV dysfunctiona
CTPA findings suggestive of pre-existing chronic thromboembolic disease
2- Concomitant chronic diseases and conditions predisposing to CTEPH (documented at PE diagnosis or at 3À6 month follow-up)
Ventriculo-atrial shunts
Infected chronic i.v. lines or pacemakers
History of splenectomy
Thrombophilic disorders, particularly antiphospholipid antibody syndrome and high coagulation factor VIII levels
Non-O blood group
Hypothyroidism treated with thyroid hormones
History of cancer
Myeloproliferative disorders
Inflammatory bowel disease
Chronic osteomyelitis
92
Strategies for patient follow-up after pulmonary embolism
Pic
