Resus Flashcards
Massive vs submassive PE definition
Massive
- acute PE with obstructive shock or SBP <90mmHg
Submassive
- acute PE without systemic hypotension (SBP>90) but with either RV dysfunction or myocardial necrosis (BNP, TnI, RV strain, RV dilatation on echo/CT)
Treatment for massive PE
Thrombolysis
Embolectomy if thrombolysis contra-indicated or failed
Anticoagulation
Consider IVC filter
Treatment for submassive PE
Anticoagulation
IVC filter if anticoagulation contraindicated
Consider thrombolysis if RV dysfunction present?
ECG findings of PE
Sinus tachycardia
SI QIII TIII
non specific ST changes or TWI in anterior leads (right heart strain)
RAD
S wave (I and aVL)
Q wave in III and aVF
p pulmonale
RBBB
Components of Well’s score + what does it mean
- PE more likely than an alternative diagnosis (3)
- suspected DVT (3)
- HR > 100 (1.5)
- Immobilisation or surgery within the previous 4 weeks (1.5)
- Previous DVT/PE (1.5)
- Haemoptysis (1)
- Malignancy (on treatment, treated in the past 6 months, or palliative) (1)
WHEN TO USE:
risk stratify patients for PE, provide a pre-test probability
Then apply either 3 or 2 tier model
THREE TIER
- low risk (2 point or less) = PERC or d dimer
- moderate risk (2-6 points) = d dimer
- high risk (>6 points) = CTA
TWO TIER
- PE unlikely (0-4 points): d dimer
- PE likely (>4 points): CTA
Components of PERC and when to use
- Age 50+
- HR 100+
- O2 sats on room air <95%
- unilateral leg swelling
- haemoptysis
- recent surgery or trauma (within the past 4 weeks, requiring GA)
- prior PE or DVT
- hormone use
WHEN TO USE
when considering PE but patient is low risk (ie after Well’s)
If low risk + PERC negative, chance of PE is <2%
Age adjusted d dimer
Add their age as a decimal place eg
under 50 = 0.5
51 = 0.51
87 = 0.87
VQ vs CTPA non pregnant
CTPA can detect clots in smaller vessels, and can uncover alternative diagnoses. CTPA is also more readily available.
Downside is CTPA has a higher radiation dose - therefore VQ is preferred in young women
CTPA also has a higher risk of contrast induced nephropathy in patients with moderate to severe renal impairment, and so VQ is preferable in these patients
VQ vs CTPA pregnancy
CT = lower radiation to foetus, particularly in earlier pregnancy
VQ = less radiation to maternal breast tissue
Thrombolysis for PE
r-tPA (Alteplase)
10mg IV bolus
followed by 90mg infusion over 2 hours
50mg IV bolus in cardiac arrest
S PESI score
Age (years) >80 (1)
History of cancer (1)
History of chronic cardiopulmonary disease (1)
Heart rate 110+ (1)
SBP <100 (1)
sPO2 <90% (1)
if all negative - mortality risk is 1.1% (low risk)
HAS-BLED
HTN >160
renal disease (creat >200, transplant, dialysis)
liver disease (cirrhosis, bili 2x normal, LFTs 3x normal)
Stroke history
Prior major bleeding or predisposition to bleeding
Labile INR
Age >65
Meds that predispose to bleeding (aspirin, clopidogrel, NSAID)
Alcohol use 8+ per week
Thrombolysis for STEMI
Tenecteplase
<60kg = 6000IU (30mg)
60-70 = 7000 (35mg)
etc up to
>90kg = 10,000IU (50mg)
consider half dose if age > 75 years
Stroke mimics
migraine aura hemiplegic migraine Todd's paralysis (post-ictal) CNS tumour or abscess functional/conversion hypertensive encephalopathy head trauma MS PRES MELAS syncope subdural systemic infection toxic metabolic disturbance carotid artery dissection extending aortic dissection CVST etc
Stroke thrombolysis
rTPA (Alteplase) 0.9mg/kg up to max 90mg
- 10% bolus then the rest over 60 mins
tenecteplase 0.25mg/kg to max 25mg over 1 minute
