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Disease 2 > pulmonary embolism > Flashcards

pulmonary embolism Flashcards

1
Q

Describe what a pulmonary embolism is

A

An obstruction of the pulmonary artery or one of its branches by material that originated somewhere else in the body

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2
Q

What material can cause a pulmonary embolism?

A

Blood clot
Air embolism
Tumor fragments
Fat
Amniotic fluid

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3
Q

Describe why the location of a pulmonary embolism is so important

A

The location of the embolism determines how much of the lung or lungs are not receiving arterial blood. An embolism that cuts off blood flow to a small portion of a lobe is much less significant than an embolism that cuts off circulation to both lungs

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4
Q

What is the most dangerous type of embolism?

A

A saddle embolism

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5
Q

A pulmonary embolism can lead to infarction. What can this result in?

A

Alveolar atelectasis
Alveolar consolidation

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6
Q

T/F: Advances in modern imaging have resulted the discovery of PE that would have otherwise gone undetected

A

True

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7
Q

A pulmonary embolism can sometimes cause an inflammatory response. What can this lead to?

A

Bronchospasm
Seems to contribute to shunt like effect on top of PE deadspace for total effect of hypoxemia

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8
Q

What is the incidence of PEs in the US?

A

38 cases per 100000 annually
100,000 deaths annually

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8
Q

How does decreased perfusion affect surfactant production?

A

Decreases surfactant production

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9
Q

What are the effects of decreased surfactant production as a result of a PE?

A

Decreased lung compliance
Atelectasis
V/Q mismatch

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9
Q

What is thrombophlebitis?

A

Condition where a blood clot forms and blocks venous return, usually in the legs but it can occur throughout the body

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10
Q

How does bone cancer increase the risk for a PE?

A

Bone cancers can lead to pathological fractures, the fractures can allow bone marrow to escape into blood stream, boom. PE

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10
Q

Why are women who are pregnant at an increased risk of PE?

A

Enlarged uterus can result in obstruction of venous return resulting in stagnant blood that can form clots

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10
Q

What pathological malignancies increase risk for PEs?

A

Multiple myeloma (bone cancer)
Tumors

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11
Q

How do tumors increase the risk for PE?

A

Potential fragmentation into bloodstream
Tumor can release procoagulant factors

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12
Q

Why are patients in the hospital at an increased risk for developing a PE?

A

They are immobilized
Potentially hypercoagulable states
Frequently have undergone major surgery

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13
Q

What other factors and conditions can increase risk of a PE?

A

Obesity
Childbirth
Supplemental estrogen
Family history of venous thromboembolism
Smoking
Burns
Pacemakers or venous catheters

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13
Q

What can lead to hypercoagulation?

A

Oral contraceptives
Polycythemia (increased RBC count)
Factor V leiden (genetic disorder that increased chances of forming clots)

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14
Q

Where do most clots form?

A

Most clots originate or break away from sites of deep venous thrombosis in the lower part of the body
Leg, pelvic veins, inferior vena cava

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15
Q

What is venous stasis and how does it contribute to clot formation?

A

Slowing or stagnation of blood flow through the veins
Stagnating blood has a higher risk of coagulation

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16
Q

What hemodynamic indices would we see on a PE patient who is crashing?

A

Decreased CO
Systemic hypotension
Increase PVR

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16
Q

How does injury to the endothelial cells increase the risk for clot formation?

A

Activation of the platelets to form a clot which can then break off

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17
Q

How would a patient who is crashing as a result of PE present?

A

Sudden onset of dyspnea, tachycardia and hypotension
Hypotension
Weak pulse
lightheaded/fainting
Anxiety
Cyanosis

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18
Q

Describe chest pain that is caused by a PE

A

May be pleuritic
May radiate
Can be sharp, stabbing, aching or dull
May intensify with exertion
Does not subside with rest

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19
Q

Describe the sputum that a patient with severe PE might produce

A

Bloodstreaked

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20
Q

T/F: a patient in critical condition with a PE may produce a wheeze

A

True

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21
Q

Describe how septic emboli form and what can happen as a result of their formation

A

Vegetations form on the tricuspid or pulmonary valve in the heart
Vegetations fragment and lodge themselves in pulmonary arteries
Vegetations fragment causing infections, abscesses, cavities and infarcts, oh my!

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22
Q

What hemodynamic indices would decrease as a result of a PE?

A

CO
SV

22
Q

What population is at risk for developing septic emboli?

A

IV drug users

23
Q

What hemodynamic indices would increase as a result of a PE?

A

CVP
RAP
PA
PVR

24
Q

T/F: A chest radiograph is useless for diagnosing a PE

A

False. While the CXR cannot determine if the patient has a PE, it can be useful for ruling out other potential causes of dyspnea.

25
Q

What can a CXR show in some patients with PE?

A

Dilated right ventricle
Right ventricular hypertrophy

26
Q

What is the gold standard for diagnosing a PE?

A

Computed tomography pulmonary angiogram

27
Q

What are some of the risks associated with CTPA?

A

Contrast can cause damage to the kidneys
Exposes the patient to radiation

28
Q

Describe how a CTPA helps us locate a PE

A

Contrast is injected into the veins to make the pulmonary vasulature appear white which allows us to see blockages

29
Q

What can be used to look for a PE if a CTPA isnt available or the patient has kidney disease/can take contrast?

A

A V/Q scan

30
Q

How is a V/Q scan performed?

A

Ventilation scan = patient inhales nebulized radioisotope and is scanned with nuclear medicine camera to visualize the airways
Perfusion scan = patient is injected with a radioisotope and scanned to image pulmonary vasculature
The two images are then compared for mismatches

31
Q

How can ultrasonography be used to detect PEs?

A

Ultrasound imaging of the lower extremities can detect deep venous thrombosis
Cardiac ultrasound can detect right heart strain

32
Q

What does the D-Dimer test for?

A

A protein fragment that is left in the blood after a clot is dissolved by fibrinolysis

33
Q

What blood test can be utilized to determine someones risk for a PE?

A

D-Dimer

34
Q

What concentration of D-Dimer is an indication for increased potential of PE?

A

Greater than or equal to 500 ng/mL

35
Q

Describe why the D-Dimer test may not be particularly useful in testing for PEs?

A

Many things can raise the D-dimer such as recent surgery or injury
Just because they have a high D-dimer level does not necessarily mean they are at risk for developing a PE

36
Q

A score of greater than 6 on the wells score is indicative of what?

A

High probability of PE

37
Q

When using the Wells score, what symptoms and factors are considered for scoring?

A

Symptoms of DVT
No better alternative diagnosis
Tachycardia > 100
Immobilization of surgery in the past 4 weeks
Prior history of DVT or PE
Presence of hemoptysis
Presence of malignancy

38
Q

A score of between 2-6 on the wells score is indicative of what?

A

Moderate probability of PE

39
Q

A score of less than 2 on the wells score is indicative of what?

A

Low probability of PE

40
Q

What are the 2 scoring systems when considering PE?

A

Wells score
PERC (Pulmonary embolism rule out criteria)

41
Q

What is PERC (pulmonary embolism rule out criteria) used for?

A

Similar to the pneumonia severity index, it helps clinicians determine whether or not a patient can be sent home

42
Q

T/F: A patient does not need to be considered low risk in order to use PERC

A

False. The provider must feel that the patient is low risk in order to apply PERC

43
Q

What is the procedure of the patient passes PERC?

A

They are ok to send home

44
Q

What is the procedure if the patient is flagged by PERC?

A

they are usually given a D-dimer test which may or may not lead to imaging

45
Q

What are the criteria for the PERC?

A

Age > 50
HR > 100
SpO2 on RA <95%
History of venous thromboembolism
Trauma or surgery in the last 4 weeis
Hemoptysis
Exogenous estrogen
Unilateral leg swelling

46
Q

Describe the classic presentation for PE

A

Sudden onset dyspnea
Sudden increase in HR
Sudden systemic hypotension
Cough, hemoptysis, pleuritic chest pain
Distress
Diaphoresis
Recent surgery or extended travel

47
Q

T/F: A patient with a PE may have distended neck veins

A

True, the embolism may be causing significant backup of blood flow resulting in venous distention

47
Q

T/F: a Patient with a PE may have a swollen and tender liver

A

True, a symptom of blood back up

48
Q

What might be detectable on a patient with a PE who has significant pulmonary hypertension?

A

Right ventricular lift

49
Q

Describe a thrombectomy

A

Surgical option for hemodynamically unstable patients
A catheter is advanced through the right femoral vein
Clot is broken up mechanically, chemically, or suctioned out
Relatively high rate of mortality \

50
Q

What patients with PEs are considered acute?

A

Hemodynamically unstable patients are considered acute

51
Q

How is acute PE typically managed?

A

Surgery
Thrombolytics
Anticoagulants

52
Q

What can be concerning regarding thrombolytics?

A

Thrombolytics actively break down clots but do so indiscriminately throughout the body, which is problematic if you are prone to bleeding? Ask steve

53
Q

What is the most common thrombolytic used?

A

Tissue plasmin activator (tPA)
Aka alteplase

54
Q

What is the purpose of anticoagulants when dealing with PEs?

A

The can help keep the clot from growing
Keep more clots from forming

55
Q

How are stable PEs managed?

A

Heparin
Supportive care including supplemental oxygen

56
Q

How are anticoagulants delivered to during treatment of a PE?

A

Unfractionated heparin delivered via IV

57
Q

How are stable PEs treated long term with anticoagulants? What drugs are used?

A

Anticoagulant therapy = warfarin (coumadin)
Direct oral anticoagulants
Eliquis (apixaban)
Xarelto ( rivaroxaban)
Pradaxa (dabigatran)

58
Q

How are stable PEs treated long term with blood thinners? What drugs are used?

A

Low molecular weight heparins taken orally
Enoxaparin (lovenox) most common

59
Q

What device can be used to help prevent PEs?

A

Inferior vena cava filter aka greenfield filter

60
Q

What are some complications associated with the greenfield filter?

A

Device migration
Filter fracture
Insertion site thrombosis
Perforation of vena cava
Thrombotic complications
Having a literal spaghetti strainer in your IVC seems bad

61
Q

Describe non-invasive and non-pharmacological management strategies for mitigating PE risk

A

Walking
Exercise while seated
Drink fluids
Graduated compression stockings
Pneumatic compression of legs in hospital

Disease 2 (16 decks)

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