PE

Question 1

where PEs come from

Answer 1

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

Question 2

PEs are often missed bc

Answer 2

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

Question 3

risk of blood clot formation

Answer 3

Virchow’s triad

Question 4

Virchow’s triad

Answer 4

hypercoagulability
stasis
venous injury

Question 5

hypercoagulability risk factors

Answer 5

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

Question 6

stasis/acquired hyper coagulable states

Answer 6

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

Question 7

venous injury

Answer 7

surgery, trauma, fx bones

Question 8

clin. features are result of

Answer 8

cardiopulmonary stress secondary to PE

Question 9

s/s PE

Answer 9

SOB*, CP (2nd), hypoxemia, tachypnea, tachycardia

may be intermittent

Question 10

more clinical features PE

Answer 10

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

Question 11

PE dx gold standard

Answer 11

pulmonary angiogram in cath lab

but use CT more often* less invasive?

Question 12

PE EKG findings

Answer 12

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

Question 13

PE ABG dx

Answer 13

hypoxemia

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

Question 14

WELLS criteria

Answer 14

see book

Question 15

PE dx D-dimer

Answer 15

“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%)

Question 16

PE dx CXR

Answer 16

Very non specific
May be normal
Elevated hemidiaphragm

Question 17

PE CXR: Westermark sign

Answer 17

sharp cutoff of pulmonary vasculature

Question 18

PE CXR: Hamptons Hump

Answer 18

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

Question 19

PE VQ scan

Answer 19

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

Question 20

PE CT chest

Answer 20

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

Question 21

PE tx

Answer 21

LMWH
Heparin (drip)
Thrombolytic tx
new oral agents

Question 22

Thrombolytic therapy

Answer 22

streptokinase, urokinase, alteplase

-directly lyse clot

Question 23

give thrombolytic therapy for

Answer 23

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

Question 24

new oral agents

Answer 24

?? not tested on

Question 25

what to do if pt can not be anticoagulated

Answer 25

recent surgery dural puncture hx of hemorrhagic/ischemic stroke

Question 26

best PE tx

Answer 26

prevention | Heparin pre-op etc.

Question 27

Heparin

Answer 27

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

Question 28

if can not be anti coagulated, use

Answer 28

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

Question 29

PE risk pops

Answer 29

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)

Question 30

what else can embolize

Answer 30

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

Question 31

PE sleep related breathing disorders definition

Answer 31

-breathing cessation for at least 10 seconds

Question 32

hypopnea

Answer 32

dec. in pulse ox by 4%

Question 33

PE iatrogenic

Answer 33

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

Question 34

PE amniotic fluid

Answer 34

dyspnea leads to cyanosis, hypotension and eventually DIC

Question 35

PE: air

Answer 35

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

Question 36

sources of apnea

Answer 36

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

Question 37

sleep related breathing disorders are associated with

Answer 37

arrhythmias

Question 38

OSA (obesity rel. sleep apnea) common clinical findings

Answer 38

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?

Question 39

OSA dx

Answer 39

sleep study

Question 40

OSA tx

Answer 40

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

Question 41

nasal CPAP

Answer 41

full mask, portable, tolerated well

Question 42

acute resp. failure definition

Answer 42

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

Question 43

ARF findings

Answer 43

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

Question 44

UPPP

Answer 44

remove part of tonsilar pillars and uvula

Question 45

definitive OSA tx

Answer 45

tracheostomy

Question 46

ARF tx

Answer 46

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

Question 47

resp support: non-ventilatory

Answer 47

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

Question 48

resp. support: ventilatory

Answer 48

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

Question 49

when use vent. support (CPAP, BIPAP)

Answer 49

ES COPD, DNR, bridge before intubation, CHF

Question 50

indications for tracheal intubation

Answer 50

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

Question 51

what would obstruct an airway

Answer 51

``` acute epiglottitis status asthmaticus trauma burns foreign bodies mucous ```

Question 52

now what after intubated

Answer 52

mechanical ventilation | bag em

Question 53

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

Answer 53

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

Question 54

Synchronized intermittent mandatory ventilation (SIMV)

Answer 54

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

Question 55

complications with mech. ventilation

Answer 55

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

Question 56

why hypotension

Answer 56

???

Question 57

ARDS def

Answer 57

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

Question 58

ARDS clinical findings

Answer 58

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

Question 59

what prevents ARDS

Answer 59

nothing

Question 60

ARDS risks

Answer 60

see table

Question 61

ARDS tx

Answer 61

ID and tx cause supportive care improve/correct hypoxemia

Question 62

for correcting hypoxemia (ARDS)

Answer 62

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

Question 63

this is not considered tx for PE

Answer 63

aspirin