Pulmonary Embolism

Question 1

What is Pulmonary embolism? What conditions (14) is it caused in?

Answer 1

Block of Pulm artery leading to ischemia of lung

In
1. DVT - prolonged, immobile while travelling
2. Surgery - THR (hip), TKR, GIT
3. Prev h/o of pulmonary embolism
4. Pregnancy, postnatal
5. OCP’s, HRT
6. Thrombophilia - Factor 5/prothrombin/protein-c deficiency
7. Malignancy
8. Right heart failure
9. Cardiac arrest
10. Hypotension
11. Obesity
12. Nephrotic syndrome
13. Rheumatic disease
14. Acute Respiratory failure

Question 2

C/F of Pulmonary Embolism

Answer 2

1. SOB - Sudden Onset
2. Pleuritic chest pain
3. Red, painful calf - DVT
4. Tachycardia > tachypnoea
5. Low O2 saturation
6. Hemoptysis
7. Can be assymptomatic/ only SOB

Question 3

Well’s score

Answer 3

Pulmonary embolism
EAT CHIPS
1. Edema/ leg pain (DVT) - 3
2. Alternative diagnosis less likely - 3
3. Tachycardia - 1.5
4. Cancer - 1
5. Hemoptysis - 1
6. Immobilization >3 days -1.5
7. Previous h/o DVT or PE - 1.5
8. Surgery <1month - 1.5

<4 - low risk… D-Dimer increased (sensitive, can be increased in preg etc)
>4 - high risk… CTPA/VQ scan

VQ scan preferred in pregnancy (radiation) and contrast allergy
VQ scan avoided in COPD/pre-existing lung conditions (difficult to read)

Question 4

VQ scan in pulmonary embolism

Answer 4

Ventilation perfusion scan
Done when Well’s score >4
Perfusion abn in PE
VQ scan preferred in pregnancy (radiation) and contrast allergy
VQ scan avoided in COPD/pre-existing lung conditions (difficult to read)

Question 5

Most appropriate, best, initial investigation in Pulmonary embolism with Well’s score > 4?

Answer 5

CTPA (CT-pulmonary angiography)
or
VQ scan (Ventilation perfusion scan)
*NOT XRAY
Well’s < 4 … D-Dimer

Question 6

When do you do ABG in Pulmonary embolism? Preferred before or after CTPA?

Answer 6

Can do before CTPA in
C/o Acute severe SOB and
O2 sat <92%

Question 7

Mx of Pulmonary embolism

Answer 7

Hemodynamically unstable
1. Thrombolytics
2. Pulm embolectomy and interrupt IVC

Hemodynamically Stable
1. NOAC/DOAC i.e., new/direct oral anti-coagulants
Apixaban
Rivaroxaban
Dabigatrin
*for 3 months
2. IVC filter

*Heparin and warfarin not used now, daily monitoring of INR in warfarin difficult

Question 8

If a pregnant patient comes to OPD with signs of DVT, which test do you recommend?
a. CTPA
b. VQ scan
c. Other

Answer 8

c. Other
Deep vein venous doppler to check for clots
Mx for DVT and PE is same
Ideal to avoid stressful investigations like CTPA/VQ scan

Question 9

Most common ECG finding in Pulmonary embolism?

Answer 9

Sinus Tachycardia
NOT S1 Q3 T3

Question 10

D-Dimer in pulmonary embolism

Answer 10

Increased if clot is present
Sensitive
If negative - can exclude pulm embolism
Not specific - increased in pregnancy and other clotting disorders

Question 11

Xray signs in Pulmonary embolism

Answer 11

Xray not required, if done shows
Atelectasis
Wedge-shaped infarction
Pleural-based lesion (Hampton hump)
Oligemia (pulmonary blood volume decrease) of one lobe (Westermark sign)