Pulmonary Circulation Disorders

Question 1

Refers to the movement of a clot (most commonly blood) from a systemic vein through the right side of the heart and into the pulmonary

Answer 1

Pulmonary Embolism

Question 2

What is the most common preventable cause of hospital death?

Answer 2

Pulmonary Embolism

Question 3

3rd most common vessel death after MI and stroke

Answer 3

Pulmonary Embolism

Question 4

Most pulmonary embolisms arise from where?

Answer 4

thrombi in venous circulation of lower extremities 🡪 thromboembolism (typically around a valve)

Question 5

What are other sources of pulmonary embolisms besides a LE thrombi?

Answer 5

Amniotic fluid
Air
Fat
Bone Marrow
Intravenous material
Septic emboli

Question 6

What percentage of PE’s originate as clots in the deep veins of lower extremities, mostly in calves

Answer 6

70%

Question 7

List some risk factors for a PE

Answer 7

Hypercoagulable States
Limb stasis (immobilization)
Prior DVT/PE
Malignancy
Age >45 years
Obesity
CHF
Trauma within the past 4 weeks
Surgery within the past 4 weeks
Major surgery
Serious infection

Question 8

Virchow’s Triad

Answer 8

Local trauma to vessel wall (endothelial injury)

Hypercoagulability

Stasis or stagnation of the blood

Question 9

Why can a diagnosis of PE be so difficult?

Answer 9

No single sign or symptom or combination of clinical findings are
indicative of a PE

there is not one single diagnostic test we can do to make the diagnosis

Question 10

What is a rule that can help with a PE diagnosis?

Answer 10

The PERC Rule – Pulmonary Embolism Rule Out Criteria
(aids - not absolute)

Question 11

When measuring and comparing the contralateral leg in suspicion for PE, what difference should you be concerned about?

Answer 11

≥2cm difference highly suspicious

Question 12

List some low pretest probability for PE:

Answer 12

Age less than 50
Pulse rate less than 100 beats/min
Oxygen saturation greater than 94%
No hormone use
No hemoptysis
No unilateral leg swelling (measure with tape, NOT eyes)
No recent major surgery or trauma
No prior PE or DVT

Question 13

What is a good predictor of the outcomes from PEs?

Answer 13

The degree of hypoxemia

Question 14

One of the first workups we’re going to do in a suspected PE?

Answer 14

Pulse Ox

Question 15

PE Workup – what Chest Xray finding is described below?

Increased opacity from intraparenchymal hemorrhage

Wedge-shaped density/area of infiltrate pointing towards hilum

Answer 15

Hampton’s Hump

Question 16

PE Workup – what Chest Xray finding is described below?

Prominent central pulmonary artery with local oligemia

Unilateral lung oligemia (absence of vasculature)

Rare sign of a very large pulmonary embolism

Answer 16

Westermark’s Sign

Question 17

What is the classic EKG finding in a PE?

Answer 17

T wave inversion in V1-V4

S1Q3T3: classic

Question 18

This non-specific test can help confirm, but not diagnostic of a PE

Answer 18

D Dimer

Question 19

What D-dimer level is strong evidence against thromboembolism?

Answer 19

less than 500

Question 20

What screening test for a PE is 90% sensitive?

Answer 20

Venous ultrasound

Question 21

What imaging is gold standard for diagnosing PE?

Answer 21

Pulmonary Angiography

Question 22

Why is Pulmonary Angiography not commonly used for PE even though it is the gold standard?

Answer 22

Minimal use secondary to toxicity issues

Also invasive - must insert a catheter int the pulmonary artery and inject dye in the cath lab

Question 23

What imaging has largely replaced Pulmonary Angiography for diagnosing PEs?

Answer 23

Helical (spiral) CT angiography

Question 24

Which imaging used to be the gold standard – was the most useful screening tool to rule out PE?

Answer 24

Ventilation-Perfusion Scan

Question 25

Which imaging is preferred for pregnant patients for evaluation of a PE?

Answer 25

Ventilation-Perfusion Scan

Question 26

The prognosis of patients with pulmonary embolism depends on what 2 factors?

Answer 26

underlying disease state appropriate diagnosis and treatment

Question 27

Approximately what percentage of patients who develop PE die within the first hour?

Answer 27

10%

Question 28

The mortality in patients with undiagnosed PE is what percentage?

Answer 28

30%

Question 29

As a cause of sudden death, massive pulmonary embolism is second only to what?

Answer 29

sudden cardiac death

Question 30

Pathological state in which the systolic pressure in the PA is consistently elevated above normal

Answer 30

Pulmonary Hypertension

Question 31

Most common cause of pulmonary hypertension is what?

Answer 31

left heart failure

Question 32

Pulmonary circulation is unique because of what factors?

Answer 32

it’s high blood flow and low pressure and low resistance

Question 33

What type of pulmonary HTN is most common?

Answer 33

secondary

Question 34

Which type of pulmonary HTN is described below? most common Hypoxic vasoconstriction Obliteration of pulmonary vasculature Volume/pressure overload

Answer 34

Secondary Pulmonary Hypertension

Question 35

Which type of pulmonary HTN is described below? Rare (often genetic) - however cause unknown Occurs mostly in young and middle aged women Progressive dyspnea, rapid downhill course (self-perpetuates) Invariably fatal if not treated – can be crippled within 6 months Characteristic histopathologic plexiform lesions found in muscular pulmonary arteries

Answer 35

Primary Pulmonary Hypertension

Question 36

What signs may you hear on auscultation in pulmonary HTN?

Answer 36

Narrow splitting of second heart sound with accentuation of pulmonary component - P2 may be fixed or paradoxical splitting Paradoxical splitting: splitting of S2 heard on expiration only (disappears during inspiration)

Question 37

What are two of the biggest signs you may find on physical exam for pulmonary HTN?

Answer 37

RFV and Cor pulmonale

Question 38

What is the is gold standard to confirm diagnosis of Pulmonary HTN?

Answer 38

Right heart catheterization

Question 39

Right sided heart failure – enlargement of the right ventricle due to high blood pressure in the arteries of the lungs usually caused by chronic lung disease

Answer 39

Cor Pulmonale

Question 40

Cor Pulmonale is most commonly caused by what lung disease in the US?

Answer 40

COPD

Question 41

What imaging is done to confirm the diagnosis of cor pulmonale?

Answer 41

Right heart catheterization

Question 42

What heart rhythm is common to see in cor pulmonale and why?

Answer 42

Atrial fib/flutter From RA dilation – the flimsiest chamber of the heart we have