Pulmonary Embolism Flashcards

(47 cards)

1
Q

Identify three embolic sources

A
  • Thrombus from venous system
  • Tumour from prostate or breast cancer
  • Fat from long-bone fracture
  • Amniotic fluid from pregnancy
  • Sepsis from IVDU
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2
Q

Identify five risk factors for a PE

A
  • DVT
  • Previous VTE
  • Active cancer
  • Recent surgery
  • Recent immobilisation
  • Lower limb trauma or fracture
  • Pregnancy and 6 weeks postpartum
  • Increasing age
  • Oral contraceptive use
  • HRT
  • Obesity
  • Comorbidities
  • Varicose veins
  • Thrombophilia
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3
Q

What proportion of VTE are PE?

A
  • 1/3
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4
Q

Identify three symptoms of PE

A
  • Dyspnoea
  • Pleuritic chest pain
  • Tachypnoea
  • Unilateral painful leg swelling
  • Dizziness or syncope
  • Retrosternal chest pain
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5
Q

Identify three signs of PE

A
  • Tachycardia
  • Hypotennsion
  • Hypoxaemia
  • Raised JVP
  • Pyrexia
  • Gallop rhythm
  • Pleural rub
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6
Q

What criteria is used to estimate probability of a PE?

A
  • Two level PE Wells score
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7
Q

Identify three criteria on PE wells score

A
  • Clinical features of DVT
  • Alternative diagnosis is less likely than a PE
  • Heart rate greater than 100
  • Immobilisation for more than 3 days or surgery in previous four weeks
  • Haemoptysis
  • Malignancy
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8
Q

What Wells score indicates a likely PE?

A
  • More than 4
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9
Q

Identify three other initial investigations that should be performed

A
  • CXR
  • ECG
  • ABG
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10
Q

What is most commonly seen on CXR, what is less commonly seeen?

A
  • Normal

LESS COMMON

  • Atelectasis
  • Pleural effusion
  • Raised hemidiaphragm
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11
Q

What is most commonly seen on ECG, what is less commonly seen?

A
  • Sinus tachycardia

LESSON COMMON

  • S1Q3T3
  • Right axis deviation
  • RBBB
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12
Q

Identify two possible findings on ABG

A
  • Respiratory alkalosis

- Type 1 respiratory failure

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13
Q

Identify three differential diagnoses of a PE

A
  • Pneumothorax
  • Acute exacerbation of asthma
  • Acute exacerbation of COPD
    ACS
  • Acute congestive cardiac failure
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14
Q

What secondary care investigation should be performed for a Wells of more than 4?

A
  • CTPA
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15
Q

A CTPA cannot be performed immediately. What should be done?

A
  • Give interim therapeutic anti-coagulation with a DOAC (apixaban or rivaroxaban)
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16
Q

What secondary care investigation should be performed for a Wells of 4 or less?

A
  • D-Dimer test
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17
Q

A D-dimer test cannot be performed within 4 hours. What should be done?

A
  • Give interim therapeutic anti-coagulation with a DOAC (apixaban or rivaroxaban)
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18
Q

What should be done if the D-dimer test is positive?

A
  • CTPA
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19
Q

Identify three indications for V/Q scanning in place of CTPA

A
  • Pregnancy
  • Renal impairment
  • Contrast allergy
  • Younger patient
20
Q

Identify four baseline values that should be obtained prior to commencing oral anticoagulant therapy

A
  • FBC
  • LFT
  • U&E
  • Coagulation studies
21
Q

Outline the management of a haemodynamically unstable patient

A
  • IV fluids over 15 minutes
  • Oxygen therapy
  • UFH prior to thrombolysis (stopped within 24 hours)
  • Thrombolysis with alteplase
22
Q

What should be administered if SBP remains less than 90 mmHg following thrombolysis?

A
  • Give inotropic agent such as noradrenaline or dobutamine
23
Q

What should be done if all interventions fail in haemodynamically unstable PE?

A
  • Perform pulmonary embolectomy
24
Q

What is PESI?

A
  • Pulmonary Embolism Severity Index

- Used to determine whether patient may be discharged or requires admission

25
Identify three conditions in which PESI should not be used
- Hypotensive - Pregnancy - Active cancer
26
Identify two factors that the PESI takes into account
- Right ventricular dysfunction | - Cardiac biomarkers.
27
What PESI score requires admission but not close monitoring?
- 3 or 4
28
What PESI score indicated outpatient management?
- 1 or 2
29
Outline the management of a PE in a patient who is haemodynamically stable who has no co-morbidities
- DOAC for 3 months | - Stop after 3 months if provoked
30
Outline the management of a PE in a patient who is haemodynamically stable who has active cancer
- DOAC for 6 months | - Stop after 6 months if provoked
31
Outline the management of a PE in a patient who is haemodynamically stable and has renal impairment
- UFH and warfarin for 5 days - Followed by warfarin alone for 3 months - Stop after 3 months if provoked
32
Outline the management of a PE in a patient who is haemodynamically stable and has triple positive antiphospholipid syndrome
- LMWH and warfarin for 5 days - Followed by warfarin alone for 3 months - Stop after 3 months if provoked
33
Identify two drugs in the class LMWH
- Dalteparin | - Enoxaparin
34
Identify three adverse effects of LMWH
- Bleeding - Injection site reaction - Heparin-induced thrombocytopenia
35
Identify the dose and administration of dalteparin in treatment of PE
- 200 units / kg (100 if increased risk of haemorrhage) - By SC injection - For 5 days in addition to warfarin
36
What can be used to partially reverse bleeding associated with LMWH
- Protamine sulfate
37
Identify three contraindications of warfarin
- 48 hours postpartum - Haemorrhagic stroke - Significant bleeding
38
Identify three adverse effects of warfarin
- Bleeding - Skin necrosis - Blue toe syndrome
39
Identify three factors that potentiate the effects of warfarin
- Macrolides (clarithromycin) - Cephalosporin (cefuroxime) - Sulfonamides (sulfasalazine) - NSAIDs (ibuprofen) - Liver disease
40
Identify three factors that lessen the effects of warfarin
- Aminoglycosides (gentamicin) - Vitamin K - Colestyramine - Pregnancy
41
Identify the dose and administration of warfarin in treatment of PE
- 5 - 10 mg initially - Subsequent doses guided by INR - Oral administration
42
What is the target INR?
- 2.5 | - 3.5 if previous VTE
43
Identify two drugs in the class Factor Xa inhibitor
- Apixaban | - Rivaroxaban
44
Identify two contra-indications of Factor Xa inhibitors
- Active bleeding - Antiphospholipid syndrome - Prosthetic heart valves - Recent intracranial haemorrhage - Recent oesophageal varices
45
Identify three adverse effects of Factor Xa inhibitors
- Haemorrhage - Nausea - Skin reactions - Anaemia
46
Identify the dose and administration of rivaroxaban in treatment of PE
- 15 mg twice daily for 21 days | - Orally
47
Identify the dose and administration of apixaban in treatment of PE
- 10 mg twice daily for 7 days | - Orally