Pulmonary embolism Flashcards
What are common symptoms of a PE?
dyspnea, chest pain, cough, tachycardia, AMS, bronchospasm, syncope, hypoxia, DVT symptoms (muscle cramping, pain, redness, swelling)
What do nearly almost all hospitalized patients qualify for especially following high-risk surgeries?
chemical VTE prophylaxis – lovenox or heparin, utilize PESI to score outpatient vs inpatient (high = admit, low = outpatient management)
What are these risk factors for:
Inherited (factor V leiden)
Acquired - provoking (trauma, surgery, hormone therapy, active cancer)
Non provoking - obesity, smoking
Virchow’s triad
PE
What’s the 3rd most common cardio COD?
PE
Where do most thromboembolisms come from?
lower extremity (proximal veins) or renal + upper extremity from lines
What’s a saddle embolism?
at bifurcation, can be “in transit” which = high mortality
50-60% of DVT patients will have ___
PE
Normal CXR with hypoxia indicates
PE
What would you see on a lung exam of a PE?
dyspnea/tachypnea with a normal lung exam, maybe a precordial heave, loud 2nd sound, gallop
What score do you use for clinical risk assessment?
Wells score
What is the Pulmonary Embolism Rule-out Criteria (what do the amount of criteria mean)?
NO criteria met = PE can be ruled out
If 1 criteria is met = obtain D-dimer
If D-dimer is negative + pre-test probability of PE is low – no further work up
Positive D-dimer = proceed w/ CT PE
What would be shown on an EKG for PE?
S1Q3T3
What are rare sightings on a CXR for a PE?
normal or wedge-shaped infiltrate, hemi-diaphragmatic elevation, effusion, pulm HTN, atelectasis
Hampton hump, Westermark sign
What scan would you do if intolerance of contrast (pregnant)?
V/Q scan
What’s your first line test for PE?
CT PE
What are the PERC rule out criterias?
> 50
HR>100
O2 sat <95%
prior Hx of DVT/PE
recent trauma/surgery
hemoptysis
exogenous estrogen
unilateral leg swelling
if none are present = rule it out!
What type of PE is this:
Hemodynamically unstable
Sustained HOTN (<90 or >40 from baseline for >/ 15 minutes, requiring vasopressor or causing cardiac arrest
Not due to any other cause
Persistent profound bradycardia (<40)
Pulselessness
high risk PE (massive) >6
What type of PE is this:
Hemodynamically stable
w/o HOTN but RV dysfunction or myocardial necrosis (troponin)
intermediate risk PE (submassive, 2-6)
What type of PE is this:
Acute PE w/o clinical markers of adverse prognosis
low risk PE <2
What’s first line for PE?
stabilize = O2, intubate, ventilation/IV fluids/vasopressors for HOTN
How do you decide inpatient or outpatient for a PE patient?
pulmonary embolism severity index
What should you start immediately for a PE patient?
anticoag - heparin immediately, + transition to warfarin, lovenox, or DOAC (first line transitioning) for a minimum of 3 months
When is 3 months of anticoags not considered?
in PROVOKED (caused) episodes w/ – the transient risk factor no longer present, isolated distal DVT, subsegmental or incidental PE, risk of bleeding high
When are anticoags indicated INDEFINITELY?
UNPROVOKED proximal DVT, unprovoked symptomatic PE, active cancer, antiphospholipid antibodies/syndrome, recurrent episode, low risk of bleeding
If anticoagulation is CI or bleeding risk is high, what should be placed?
IVC filter – preferred to remove when resolved @ 1 year
For severe PE, what’s the treatment?
catheter-directed embolectomy/thrombolysis,, surgical thrombolysis
When is thrombolysis not possible for PE patients?
active bleeding, stroke w/n 3 months
probably not in: uncontrolled HTN, surgery or trauma w/n past 4 weeks
If a thrombolysis is not possible for a severe PE, what do you do?
embolectomy
What are general considerations to consider as exceptions to anticoagulation?
cancer, pregnancy, patients w/ indefinite anticoagulation
PERC Rule – mnemonic (HAD CLOTS)
H – hormone use
A – age > 50
D – DVT/PE history
C – Coughing blood
L – Leg swelling (unilateral)
O – O2 < 95%
T – Tachycardia 100+
S – Surgery/trauma < 28 days
gold standard for PE dx?
angiography
wells: eat chip
Edema or DVT signs (3)
Alternative Dx unlikely (3)
Tachy (1.5)
Cancer w/n 6 months (1)
Hemoptysis (1)
Immobilization x3d / surg in past 1 month (1.5)
Previous Hx of DVT (1.5)
