Pulmonary Embolism and Hypertension

Question 1

name 2 thromboembolic diseases

Answer 1

Deep venous thrombosis (DVT)

Pulmonary embolism PE

Question 2

d: PE

Answer 2

blockage of a pulmonary artery by a blood clot, fat, tumour or air

Question 3

d: pulmonary infarction

Answer 3

If blood flow and oxygen to the lung tissues is compromised the lung tissue may die.

Question 4

A thrombus in _____ is most likely to embolise

Answer 4

Proximal (Ileo-femoral)

Question 5

A thrombus in _____ is least likely to embolise

Answer 5

Distal (Polpiteal)

Question 6

what type of thrombus is most likely to lead to chronic venous insufficiency and venous leg ulcers?

Answer 6

Proximal (Ileo-femoral)

Question 7

Symptoms DVT

Answer 7

Whole leg or calf involved depending on site

Swollen, hot, red, tender

Question 8

what are differential symptoms of DVT?

Answer 8

Popliteal synovial rupture (Baker’s cyst)
Superficial thrombophlebitis
Calf cellulitis

Question 9

How would you investigate DVT?

Answer 9

Ultrasound Doppler leg scan (1st line)

CT scan

Question 10

What does an US leg scan exclude and why is it good?

Answer 10

popliteal cyst and pelvic mass

non-invasive

Question 11

Symptoms of large PE

Answer 11

cardiovascular shock
low BP
central cyanosis
sudden death

Question 12

Symptoms of medium PE

Answer 12

pleuritic pain
haemoptysis
SOB

Question 13

Symptoms of small large PE

Answer 13

progressive dyspnoea
pulmonary hypertension
R heart failure

Question 14

Name some risk factors for DVT and PE

Answer 14

Thrombophilia- FH, freq, site, age
Contraceptive pill (particularly if smokes), HRT
Pregnancy
Pelvic obstruction e.g. uterus, ovary, lymph nodes
Surgery e.g. pelvic, hip, knee
Immobility e.g. bed rest, long haul flights
Malignancy
Obesity
Pulmonary hypertension
Vasculitis
Trauma e.g. road traffic accident

Question 15

Name some preventors of DVT

Answer 15

Early post-op mobilisation
TED compression stockings
Calf muscle exercises
Subcutaneous low dose low mol wt heparin perioperatively (Dalteparin- Fragmin)
Direct Oral Anticoagulant (DOAC) medication

Question 16

name the Direct oral anticoagulant drugs given when DVT suspected and what they do?

Answer 16

Dabigatran - direct thrombin inhibitor

Rivaroxaban/Apixaban -direct inhibitor of activated factor Xa

Question 17

Findings on examination vitals and general resp exam for PE

Answer 17

Tachycardia, tachypnoea, cyanosis,
fever,
Low BP, crackles, rub, pleural effusion

Question 18

Describe ABGs in PE?

Answer 18

decreasedPaO2 decreased SaO2 (Type 1 resp failure:PaCO2 normal or low)

Question 19

is a PE a type 1/2 resp failure?

Answer 19

Type 1

Question 20

describe CXR in PE?

Answer 20

Normal early on before infarction
Basal atelectasis, consolidation.
Pleural effusion

Question 21

name the two scores used to determine PE risk?

Answer 21

Wells

Revised Geneva

Question 22

Name the investigations for PE and what expecting from them?

Answer 22

Pulmonary Embolism Severity Index (PESI)
ECG: Acute Right heart strain pattern
(S1Q3T3; T inversion in V1-3)
D-dimers usually raised
Troponin +/- BNP/pro-BNP
Isotope lung scan (Ventilation/Perfusion: V/Q
Sensitive for small peripheral emboli
Perfusion defect before infarction
Perfusion+Ventilation matched defect after infarction
CT pulmonary angiogram (CTPA) to image pulmonary artery filling defect
to pick up larger clots in proximal vessels
Consider leg and pelvic ultrasound to detect silent DVT
Echocardiogram to measure pulmonary artery pressure and right ventricular size; acute dilatation of RV in keeping with acute PE

Question 23

Which test will actually help confirm PE?

Answer 23

CT pulmonary angiogram (CTPA)

Question 24

what other things should you consider if its not PE?

Answer 24

Consider if no obvious underlying cause
e.g. surgery /pregnancy /malignancy /immobility 
Consider cancer
Clinical exam; CXR, PSA, CA125
Pelvic USS or CT Abdo/pelvis
Autoantibodies (SLE)
Antinuclear, Anti-Cardiolipin Abs

Question 25

what test do you use If unwell with suspected intermediate to high risk PE?

Answer 25

CTPA

Question 26

what test do you use In the ambulatory setting with a low risk PE patient who has no previous respiratory disease (normal CXR)?

Answer 26

V/Q | CTPA

Question 27

what test do you use for suspected PE in pregnant woman?

Answer 27

ultrasound of legs if +ve clinical findings and assume PE if clinical supporting features OR perfusion only scan (Q scan). Reduce or avoid radiation to breast tissue where possible. However, if very unwell best modality is CTPA so accept risk of radiation to breast and baby.

Question 28

Describe how a low risk PE is managed?

Answer 28

Low risk: low PESI; -ve troponin; no oxygen; no co-morbidities Ambulatory pathway  Home

Question 29

Describe how a high risk PE is managed?

Answer 29

with cardiovascular compromise who may require thrombolysis BP monitoring Medical High Dependency Unit (MHDU)

Question 30

Describe how a medium risk PE is managed?

Answer 30

ward vs MHDU

Question 31

treatment of DVT/PE?

Answer 31

Anticoagulation prevents clot propagation tips balance to thrombolysis / body dissolves clot Therapeutic dose of S/C Low molecular weight heparin LMWH –Dalteparin/Fragmin Rarely IV heparin Empirical treatment if high clinical suspicion whilst await confirmation with investigations If low suspicion await test results before treatment If moderate suspicion weigh pros vs. cons. of empirical treatment LMWH –once daily injection; no monitoring Start warfarin simultaneously Antagonises Vit K dependent prothrombin Takes three days After 3-5 days stop heparin-when INR>2 Alternatively solely use DOACs - direct oral thrombin inhibitor (dabigatran) or factor X inhibitor (Rivaroxaban/Apixaban) less hassle and in most cases as effective as heparin/warfarin

Question 32

name some things that may interfere with treatments?

Answer 32

Alcohol, Antibiotics, Amiodarone, Cimetidine, Grapefruit… Anti-platelets or drugs which increase bleeding tendency Aspirin, NSAIDs, Clopidogrel

Question 33

name some treatments of PE only

Answer 33

Thrombolysis- tissue plasminogen activator (tPA) - tenecteplase IVC filter to prevent embolisation from large ileofemoral/IVC clot - for recurrent PEs Thrombo-embolectomy –rarely indicated Intra-catheter directed thrombolysis EKOS (ultrasound enhanced catheter thrombolysis)

Question 34

describe pulmonary circulation in terms of flow, pressure, normal mean pulmonary arterial pressure?

Answer 34

high flow low pressure mPAP is 12-20 mmHg

Question 35

what value is pulmonary hypertension?

Answer 35

25mmHg

Question 36

how is Pulmonary hypertension measured?

Answer 36

right heart catheter

Question 37

How can Systolic pulmonary arterial pressure be estimated?

Answer 37

estimated with ECHO doppler

Question 38

causes of pulmonary venous hypertension

Answer 38

Left Ventricular Systolic Dysfunction - ischaemic Mitral Regurgitation / Stenosis Cardiomyopathy-e.g. alcohol ,viral

Question 39

causes of primary pulmonary hypertension

Answer 39

Hypoxic – COPD , OSA , Pulmonary fibrosis Multiple PE –chronic thromboembolic PH (CTEPH) Vasculitis –e.g. SLE , PAN ,Systemic Sclerosis Drugs e.g. appetite suppressants - fenfluramine HIV Cardiac Left to right shunt – ASD, VSD