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Flashcards in Pulmonary Circulation/haemoptysis Deck (53):
1

where do most emboli originate from in PE

the deep veins of the leg
more rarely they can originate fro the upper limb

2

Paradoxical emboli can present in the arterial system such as in a cerebrovascular event. What three conditions can produce paradoxical emboli?

conditions producing a right to left shunt:
1) atrial/ventricular septal defects (patent foramen ovale, post MI, pulmonary hypertension)
2) Patent Ductus Arteriosus
3) AV malformations

3

which pulmonary artery passes through the pericardium for the longest

the right pulmonary artery passes horizontally through the pericardium anterior to the left main bronchus.

4

From which arteries do the bronchial arteries arise?

RIGHT: the third right intercostal artery (a branch off the aorta)
LEFT: arise at the level of T5
superior--> antero-medial surface of the aortic arch (lateral to carina)
inferior --> directly from the aorta

5

what are the differences between the bronchial and pulmonary circulations? what links them?

the bronchial arteries:
- smaller proportion of cardiac output (pulmonary arteries receive entire cardiac output)
- higher pressure as systemic
-supplies blood to air ways
- can cause massive haemoptysis
They are linked by the ligamentum arteriosum

6

what clinical sign is present in a patent ductus arteriosus

continuous machine like murmur

7

what is transposition of the great vessels and how is it treated?

the aorta and the pulmonary trunk are switched and therefore the baby is reliant upon the ductus arteriosus. The child becomes symptomatic upon the closure of the ductus arteriosus 2-3 weeks after birth.
treatment is with prostaglandins to maintain patency followed by surgery.

8

what is Virchow's triad and what does it describe

The predisposition to thrombosis following an alteration in:
1) blood flow
2)blood constituents
3) injury to the endothelium

9

what might alter blood flow

SLUGGISH BF:
- immobility (incompetent venous valves, compression of VC, cardiac failure)
- AF
- cardiomyopathy and dilated ventricle
- ventricular and aortic aneurysms
TURBULENCE:
- prosthetic/infected valves
- bifurcation of vessels

10

What might alter the constituents of blood

- increased cells (polycythaemia, thrombocythaemia, leukaemia)
- dehydration
- nephrotic syndrome
- disturbed clotting factors

11

what might endothelial inury

- surgery (pressure on limbs)
- trauma
- inflammation/vasculitis
-hypertension
- bacterial toxins
- chemo/radiotherapy
- turbulent flow
- smoking
- hyperlidiaemia

12

list 6 causes of venous emboli

1) DVT
2) fat embolism
3) gas embolism
4) amniotic fluid embolism
5) tumour embolism
6) schistosomiasis

13

list 8 causes of arterial emboli

1) AF
2) mitral stenosis
3)atrial myxomas
4) thrombi overlying MIs
5) ventricular or aortic aneurysm
6) infected or prosthetic valve
7) atherosclerotic plaque
8) vasculitis

14

list the 4 major causes of atheromatous plaques

1) hypertension
2) hyperlipidaemia
3) cigarette smoking
4) diabetes mellitus

15

what is the definition of pulmonary hypertension

MEAN pulmonary arterial pressure of >25mmHg measured at rest from right heart catheterisation

16

pulmonary hypertension can be split into 5 groups, breifly describe each one

1) pulmonary arterial hypertension - right sided heart disease
2) pulmonary venous hypertension - left sided heart disease
3) pulmonary hypertension associated with hypoxaemia - respiratory disease (esp interstitial lung)
4) pulmonary hypertension due to chronic thromboembolic disease
5) miscellaneous (sarcoidosis, histiocytosis X, lymphangiomatosis, compression of pulmonary vessels)

17

list some connective tissue disorders associated with pulmonary arterial hypertension

Scleroderma
SLE
mixed connective tissue disease
antiphospholipid disease
rheumatoid arthritis

18

what are the symptoms of pulmonary hypertension

often silent until right heart failure prevails, often misdiagnosed as athma, COPD or hysteria
- progressive dyspnoea
- fatigue
- palpitations
- chest pain
- cough/haemoptysis
- syncope

19

what ECG changes might you expect in pulmonary hypertension

Right ventricular hypertrophy:
- right axis deviation (isoelectric lead V5,6 instead of 3,4; negative QRS in lead I and tall QRS in lead II)

Right atrial enlargement:
- Tall peaked T-waves
- P-wave >2mm in lead II

20

what might you see on an echo in pulmonary hypertension

tricuspid regurgitation

21

what might you see on a CXR in pulmonary hypertension

hilar enlargement
enlargement of the pulmonary arteries
pruning of the peripheral arteries

22

why should pregnancy be avoided in pulmonary arterial hypertension

high mortality rate (30-50%) therefore patients should be counselled about using contraception:
- barrier methods
- POP
- mirena coil

23

what causes septic emboli

IV DRUG USERS!!!
pelvic thrombophlebitis
infected venous catheter/pacemaker wire
skin infections

usually staphylococci

24

describe the presentation of an acute minor PE

often with infarction:
- SOB
- pleuritic pain
- haemoptysis
- fever

25

clinical signs which may be present in PE

pleural friction rub
pleuritic pain
signs of effusion (stony dull percussion, reduced expansion, reduced breath sounds and vocal resonance)
signs of DVT (unilateral, oedema, warmth, tenderness)
elevation of the JVP

26

what is the gold standard investigations for PE

CTPA

27

what might you see on an ECG in PE

sinus tachy
massive PE:
-ST/T changes in V123
-right axis deviation
- S1Q3T3 pattern --> right heart strain
- right bundle branch block

28

what basic tests should be carried out on all PE presentation

ABGs on air
CXR
ECG
D-dimer

29

which score is used to determine a patients risk of developing a PE

modified Wells

30

which score is used in the risk stratification for the management of PE

Pesi score

31

what might prompt you to investigate for inherited thrombophillia

young age
recurrent VTE
FHx
unusual site
recurrent foetal loss/still birth
complications late in pregnancy
warfarin-induced skin necrosis

32

list some inherited thrombophillias

factor V leiden
anti-thrombin activity
protein C deficiency
protein S deficiency
prothrombin G20210A mutation

33

list some acquired thrombophillias

anti-phospholipid syndrome
anti-cardiolipin antibody
anti beta 2 glycoprotein 1
lupus anticoagulant
elevated factor VIII
JAK2 mutations
HIT

34

What is HIT

heparin induced thrombocytopenia
heparin dependant IgG antibodies bind to heparin/platelet factor 4 complexes, this activated platelets and produces a hypercoagulable state.
This causes thombus or thrombocytopenia 5-10 days after starting heparin

35

which presentations should make you think of HIT

- adrenal haemorrhagic necrosis (recent onset of Addison's)
- necrotising skin lesions at injection site
- acute systemic reaction

36

define haemoptysis

coughing up blood/bloody sputum from below the larynx

37

common causes of streaks/small clots

SMOKERS (bronchitis)
pneumonia/TB
Bronchiectasis
Lung Ca
Heart failure
PE
Anti-coagulants/aspirin

38

common causes of massive haemoptysis (>100ml)

bronchiectasis
lung Ca
TB (active or healed)
aspergilloma
vascular abnormalities
vasculitis

39

which therapeutic agents may be given to stop massive haemoptysis

tranexamic acid
nebulised adrenaline (3ml or 1:1000)

40

what are the vascular disorders which may cause haemoptysis?

pulmonary infarction
AV malformation
Elevated pulmonary venous pressure (HF/MS)
pulmonary veno-occlusive disease
bronchial arteries
pulmonary arteries
capillaries

41

which airways diseases can cause haemoptysis

acute/chronic bronchitis
bronchogenic carcinoma
metastatic cancer
bronchiectasis
bronchial adenoma/carcinoids
sarcoidosis
Kaposi's sarcoma
foreign bodies
airway trauma
Dieulafoy's/bronchovascular fistulae

42

which infective parenchymal diseases may cause haemoptysis

TB
pneumonia
lung abscess
aspergilloma
mycetoma

43

which inflammatory/immune parenchymal diseases may cause haemoptysis

Wegener's granulomatosis (vasculitis with granulomatosis)
Goodpasture's syndrome (associated with renal symptoms)
lupus pneumonitis
rheumatoid
scleroderma
idiopathic pulmonary haemosiderosis

44

what other causes of haemoptysis are there other than vascular, airway or parenchymal disease

coagulopathy
cocaine use
catamenial
trauma
idiopathic

45

what are the DDx of consolidation on a CXR

1. infection
2. water
3. tumour
4. proteinacious fluid
5. blood

46

what are the DDx for a cavitating mass on CXR

1. squamous cell carcinoma
2. lung abscess
3. rheumatoid nodule
4. embolus
5. vasculitis with granulomatosis
6. bronchogenic cyst
7. hydatid cyst

47

what are the signs of bronchiectasis

finger clubbing
coarse inspiratory crackles
wheeze
(often copious purulent sputum but can be dry)

48

define bronchiectasis

permenant dilation of bronchi and bronchioles resulting from chronic bronchial sepsis

49

what is the difference between bronchiectasis and traction bronchiectasis

bronchiectasis -> signet ring sign on CT --> airways wider than vessels
traction bronchiectasis --> honey comb changes on CT--> pulmonary fibrosis pulls open airways

50

what are the causes of bronchiectasis

CONGENITAL
CF
young's syndrome
primary ciliary dyskinesia
Kartagener's syndrome
INFECTIVE
measles
childhood pneumonia
childhood pertussis
bronchiolitis
TB/HIV
CHRONIC BRONCHIAL OBSTRUCTION
CHRONIC APIRATION
ABPA
HYPOGAMMAGLOBULINAEMIA
RHEUMATOID ARTHRITIS
ULCERATIVE COLITIS
IDIOPATHIC

51

What is the triad associated with Kartagener's syndrome

situs inversus
abnormal frontal sinuses
primary ciliary dyskinesia

52

what are the complications of bronchiectasis

infective exacerbation
pleural effusion
haemoptysis (can be massive)
cerebral abscess
amyloidosis
respiratory failure
cor pulmonale

53

Differentials of bronchiectasis

COPD
asthma
chronic sinusitis
pneumonia