Pulmonary Embolism

Question 1

epidemiology - mortality, race, age, sex, Ax & etiology, most risk

comorbidities (5)

Answer 1

• 15% mortality
• african american > whites
• DP age
• M=F
• difficult to detect; 50% idiopathic
• most risk: air travel

comorbidities:
- htn
- surgery within 3m
- immob within 30d
- cancer
- obesity

Question 2

risk factors (15)

predictors for mortality (5)

Answer 2

risk factors
- age, obesity, smoking, FMHx
- travel, pregnancy/pills/hormonal therapy
- arterial disease, stroke, trauma, acute infection, COPD
- pacemaker, catheter

predictors for mortality
- SBP < 100, HR > 100, > 70y
- CHF, chronic lung, cancer

Question 3

inherited - (1=1=2), extra (2)

acquired - (2)

more common

Answer 3

inherited/primary
- factory V leiden = activated protein C resistance
- protein C & S deficiency
- antithrombin III deficiency
- prothrombin gene mutation 20210

acquired/secondary
- more common
- hyperhomocyst, antiphospholipid antigen syndrome

Question 4

virchow’s triad (3=1)

DVT - if one entity, PE lead to (3)

post phlebitic - etiology, when, d/t=what, sx (4), tx

Answer 4

virchow’s triad
- circulatory stasis, hypercoagulability, endothelial damage = thrombosis

DVT
- one entity = VTE
- PE = fatal, chronic thromboembolic pulmonary Htn, recurrent VTE

post-phlebitic syndrome
- late adverse of DVT (several years)
- d/t permanent damage to venous valves of legs exudation of interstitial fluid
- sx: ankle & calf swelling, aches p prolonged stand, skin ulcer
- tx: no effective

Question 5

patho (3.2.1.1.3)

Answer 5

• inc pulmonary resistance: vascular obstruction, neurohormonal agents, PA baroreceptors
• impaired exchange: hypoxemia, inc alveolar dead space
• inc alveolar hyperventilation: reflex stimulus of irritant receptor
• inc pulmonary resistance: bronchoconstriction
• dec pulmonary compliance: lung edema, hemorrhage, loss of surfactants

Question 6

sx (2)
signs (5)

massive PE sx (4)

Answer 6

• DYSPNEA, pleural/atypical chest pain
• TACHYPNEA, tachycardia, tricuspid murmur, P2, low fever

massive PE = more dyspnea, no chest pain, syncope, cyanosis

Question 7

dx - points, (2.3.2), diagram

Answer 7

• > 4 = high probability
• 3 points: DVT, unlikely ddx > PE
• 1.5 points: previous DVT/PE, surgery or immob within 4w, HR >100/min
• 1 point: cancer tx within 6m or metastatic, hemoptysis
• suspected PE = history, exam, CXR, ECG
• clinical decision rule < 4 = d-dider –> if high = chest CT
• clinical decision rule > 4 = chest CT

Question 8

ancillary

d-dider (1.6)
electro (2.1)
chest radio (2.1)

Answer 8

D-DIDER
- a: blood test; if normal then unlikely PE
- d: sepsis cancer post-op pregnancy MI pneumonia = elevated

ELECTROCARDIOGRAM
- a: acute cor pulmonale, benign pericarditis
- d: nonspecific

CHEST RADIO
- a: ddx (pneumothorax), minor abnormalities but pathognomonic
- d: nonspecific

Question 9

ancillary

chest CT (1.1)
lung scanner (2.3)
MRI (1.1)
echo (2.2)

Answer 9

CHEST CT SCAN
- a: gold
- d: nonspecific if old

LUNG SCANNER
- a: high = detect PE, normal/near normal = exclude PE
- d: mostly neither, equivocal results, out of favor

MRI
- a: anatomy, cardiac function
- d: limited/preliminary

ECHOCARDIOGRAM
- a: (R) ventricle, early warning of adverse
- d: nonspecific, mostly normal

Question 10

ancillary

pulmo angio (1.1)
venous (2.3)
contrast (3.2)

Answer 10

PULMONARY ANGIOGRAPHY
- a: catheter tx
- d: invasive

VENOUS ULTRASONOGRAPHY
- a: proximal DVT, surrogate for PE
- d: can’t see iliac vein, need man for calf vein, can’t see if DVT fully embolized

CONTRAST VENOGRAPHY
- a: old gold, for calf DVT, catheter tx
- d: chemical phlebitis, can’t see massive DVT

Question 11

massive (2.3)
mod (2.3)
small (1.1)

Answer 11

massive
- sx: 50% obstruction, hypotension, cyanosis, syncope, SOB
- tx: heparin, mechanical or thrombolytic

mod to large
- sx: 30%, normal SBP
- tx: heparin, optional

small
- sx: normal BP
- tx: heparin

Question 12

infarction (0.2)
PE (1.2)
nonthrombotic (4.1)

Answer 12

pulmonary infarction
- tx: heparin, NSAIDS

PE
- sx: sudden (stroke)
- tx: heparin, shunt

nonthrombotic embolism
- air, fat, tumor, amniotic fluid
- tx: supportive

Question 13

pulmonary infarct - d/t, sx (7), exam when, tx

Answer 13

• d/t peripheral embolus in peripheral pulmonary artery near pleura not center
• sx: pleuritic chest plane wax/wane, pleural rub, leukocytosis, hemoptysis, elevated ESR, fever, lung consolidation
• exam: radiologic infarct 3-7d p embolism
• tx: not respond to meds

Question 14

mx - meds (2.2), other (2), assess (3) + if low vs. high risk (1.3)

Answer 14

• anticoagulant: heparin, coagabalin
• fibrinolysis: ase
• vena cava filter, embolectomy
• troponin + pro BNP + BNP
• high risk = anticoagulant, thrombolysis, embolectomy
• low risk = anticoagulant