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Flashcards in PE Deck (63):
1

where PEs come from

anything proximal to popliteal can embolize, below can propagate then embolize

2

PEs are often missed bc

symptoms may be vague, need high clinical suspicion
atypical symptoms of no symptoms at all
3rd leading cause of death in hospitalized pts.

3

risk of blood clot formation

Virchow's triad

4

Virchow's triad

hypercoagulability
stasis
venous injury

5

hypercoagulability risk factors

Ca, pregnancy/high estrogen
Protein C or S def.
antiphospholipid syndrome
prothrombin 202010 gene mutation
antithrombin def.
pneumonia
anemia

6

stasis/acquired hyper coagulable states

bed-ridden, wheelchair bound, cast, recent travel, advanced age

7

venous injury

surgery, trauma, fx bones

8

clin. features are result of

cardiopulmonary stress secondary to PE

9

s/s PE

SOB*, CP (2nd), hypoxemia, tachypnea, tachycardia
(may be intermittent)

10

more clinical features PE

Hemoptysis (TB also)
Fever (of "unknown origin")
Epigastric pain
Cardiac arrest (lack of hx, "throw thrombolytic at")
CP usually pleuritic (worse w/ breathing)
Syncope
Unilateral leg pain
Anxiety

11

PE dx gold standard

pulmonary angiogram in cath lab
but use CT more often* less invasive?

12

PE EKG findings

S1Q3T3
Sinus tachycardia*
RBBB
Non-specific ST changes*
Normal!!!*
Very non specific

13

PE ABG dx

hypoxemia
resp. alkalosis
v. non-specific
*not used much

14

WELLS criteria

see book

15

PE dx D-dimer

"blood clot" test
inaccurate after 72 hrs of sx if no more clot formation
-helpful if negative, but not v. specific (45%) but sens. (95-97%)

16

PE dx CXR

Very non specific
May be normal
Elevated hemidiaphragm

17

PE CXR: Westermark sign

sharp cutoff of pulmonary vasculature

18

PE CXR: Hamptons Hump

pleural based, wedge shaped consolidation with the base against the pleural surface

19

PE VQ scan

Ventilation/perfusion mismatch (where perfusing, where ventilating)
(Negative, low prob, high prob, indeterminate)
Used to be most widely used, now replaced by CT

20

PE CT chest

Spiral CT scan chest with IV contrast
Finds smaller non-obstructing and possibly more incidentalomas
(most widely used modality in US)
Quite sensitive and specific

21

PE tx

LMWH
Heparin (drip)
Thrombolytic tx
new oral agents

22

Thrombolytic therapy

streptokinase, urokinase, alteplase
-directly lyse clot

23

give thrombolytic therapy for

Echocardiogram with high RV pressure
Unstable pt (hypotensive, respiratory failure)
Very large bilateral PE (saddle embolism)

24

new oral agents

?? not tested on

25

what to do if pt can not be anticoagulated

recent surgery
dural puncture
hx of hemorrhagic/ischemic stroke

26

best PE tx

prevention
Heparin pre-op etc.

27

Heparin

binds thrombin, blocks clotting cascade, allows lysis
dosed over to coumadin/lovanox (oral) (6 mos)
may be on tx temp. if temp. risk factor (pregnant)
-should be on long-term if constant risk factor (genetic predisp)
higher risk of hemorrhage

28

if can not be anti coagulated, use

IVC filter: basket placed in IVC, catches clot
(removed w/in 2 yrs)
manual thombectomy (if large PE)

29

PE risk pops

Ca pts: Hypercoaguable state, ports and long term IV sites and ports, and fatigue with decreased mobility

pregnancy-heparin or LMWH (does not cross placenta) NOT warfarin/coumadin (does cross placenta)

30

what else can embolize

fat: trauma from long bone or pelvis fx
air, preg, iatrogenic, etc

31

PE sleep related breathing disorders definition

-breathing cessation for at least 10 seconds

32

hypopnea

dec. in pulse ox by 4%

33

PE iatrogenic

tips of catheters, guide wires during procedures, talc (drug use), starch, cellulose from meds or IDA

34

PE amniotic fluid

dyspnea leads to cyanosis, hypotension and eventually DIC

35

PE: air

central line placement, barotrauma (diving), or AV defect w/ air bolus

36

sources of apnea

Central-effort is absent
Obstructive-effort persists but no airflow occurs
Mixed-absent effort comes before obstruction

37

sleep related breathing disorders are associated with

arrhythmias

38

OSA (obesity rel. sleep apnea) common clinical findings

obese middle aged man
HTN, cor pulmonale
Daytime somnolence, work problems, FALLS ASLEEP DURING EXAM OR HPI!!
Impaired thinking or concentration, depression
Weight gain, excessive soft tissue in oral cavity, large tonsils, narrowed airway or large tongue.
Impotence
Loud cycles of snoring
Apnea
Disturbed, restless sleeping
Erythrocytosis-why?

39

OSA dx

sleep study

40

OSA tx

Lifestyle modifications:
Weight loss, avoid alcohol and sedative meds
Nasal CPAP
Uvulopalatopharyngoplasty (UPPP) and other anatomic corrections
tracheostomy

41

nasal CPAP

full mask, portable, tolerated well

42

acute resp. failure definition

Abnormality of oxygenation or ventilation (elimination of CO2) leading to possible multisystem organ failure
PO2 less than 60mm Hg, PCO2 over 50mm Hg

43

ARF findings

dyspnea, hypoxia, (alt ment stat) AMS, ha

44

UPPP

remove part of tonsilar pillars and uvula

45

definitive OSA tx

tracheostomy

46

ARF tx

tx underlying cause: i.e. pneumonia secretions (pulm. toilet)
resp. supportive care to improve gas exchange w/ goal over 90% pulse ox
gen. supportive care

47

resp support: non-ventilatory

Nasal cannula (1-3L/min) (now up to 6L/min-high flow)
Venturi mask 24-40% FIO2

48

resp. support: ventilatory

Noninvasive positive pressure-full face mask or nasal
(Bipap>Cpap)
Tracheal intubation
Mechanical ventilation

49

when use vent. support (CPAP, BIPAP)

ES COPD, DNR, bridge before intubation, CHF

50

indications for tracheal intubation

Hypoxemia despite attempt to correct
Upper airway obstruction Impaired airway protection
Severe respiratory acidosis
MS changes
Respiratory fatigue or maintained increased work of breathing
Apnea

51

what would obstruct an airway

acute epiglottitis
status asthmaticus
trauma
burns
foreign bodies
mucous

52

now what after intubated

mechanical ventilation
bag em

53

controlled mechanical ventilation (CMV) or assist control (AC)

Gives breath when triggered and otherwise scheduled
Full tidal volume breaths
(will push to tidal volume when breathing)

54

Synchronized intermittent mandatory ventilation (SIMV)

Pt triggered breaths are not supported with tidal volume
(can breath naturally outside of that, will pull in whatever you'll pull in-does not supplement)

55

complications with mech. ventilation

Displacement of ETT, barotrauma (inc. pressures-->pneumothorax; more likely on CMV), acute respiratory acidosis from over ventilation, hypotension, pneumonia, strictures (lungs, trachea), etc

56

why hypotension

???

57

ARDS def

Acute hypoxemic respiratory failure following a systemic or localized injury/insult without heart failure
Typically occurs within one week of event

58

ARDS clinical findings

Rapid onset
Dyspnea with profound hypoxemia
Diffuse patchy bilateral infiltrates on imaging

59

what prevents ARDS

nothing

60

ARDS risks

see table

61

ARDS tx

ID and tx cause
supportive care
improve/correct hypoxemia

62

for correcting hypoxemia (ARDS)

Intubation with high PEEP(positive end expiratory pressures) (small volumes)
Occasional prone positioning
Avoid O2 toxicity

63

this is not considered tx for PE

aspirin