trigger - pulmonary circulation disorders

Question 1

PE type resulting from long bone fractures

Answer 1

fat PEs

Question 1

MC sign and MC symptom of PE

Answer 1

tachypnea and dyspnea

Question 2

wells criteria of 5

Answer 2

moderate risk

remember:
>6 = high
2-6 = intermediate
<2 = low

Question 3

what is the next step after determining that the wells score is “low”

Answer 3

use PERC rules! if even one is positive you MUST get D-dimer!

Question 4

if a patient is 67 what is their expected D-dimer

Answer 4

below 670ng/mL

if patient is above 50, use the equation:
age x 10ng/mL

Question 5

caution with metformin

Answer 5

CTA

Question 6

what imaging is used for pregnant patients with suspected PE

Answer 6

VQ scans

Question 7

area of lung oligemia - usually from complete lobar artery obstruction

Answer 7

westermarks sign

Question 8

dome-shaped dense opacification in the periphery of the lung. indicative of pulmonary infarction

Answer 8

hamptons hump

Question 9

what is the risk stratification for high risk PE (massive)

Answer 9

ANY of the following:
- SBP<90 for >15 min
- drop in SBP >40 mmHg below basline
- hypotension requiring vasopressors
- cardiac arrest

Question 10

risk stratification for intermediate risk PE

Answer 10

• signs of R sided HF
• elevated trop or BNP

Question 11

what should you NOT do in PE patients d/t risk of right sided HF

Answer 11

give excess IV fluids

Question 12

binds to and accelerates activity of antithrombin

Answer 12

unfrac heparin

Question 13

obtain aPTT every 6 hours during tx

Answer 13

unfrac heparin

Question 14

this anticoagulant is reserved for unstable patients or pateints with severe renal insufficiency

Answer 14

unfrac heparin

Question 15

dose: 80 units/kg/dose IV then 18units/kg/hour (max 2000)

Answer 15

unfrac heparin

Question 16

preferred in pts who cant take oral anticoags

Answer 16

LMWH

Question 17

requires monitoring in obese and underweight patients (<45kg) or patients with renal impairment

Answer 17

LMWH

Question 18

BID then QD after 21 days

Answer 18

rivaroxaban (xarelto)

Question 19

which anticoags require bridging

Answer 19

• dabigatran (pradaxa) - 5-10 days w/UFH or LMWH
• warfarin - w/LMWH until INR is 2-3

Question 20

anticoag with once daily SQ dosing

Answer 20

fondaparinux (arixtra)

Question 21

pt has intermediate risk with elevated trop and BNP with persistent hypoxia. what is treatment?

Answer 21

tPA!

indicated in high risk
indicated in intermediate w/ elevated trop OR BNP OR hypoxemia w/ distress

Question 22

pt has an active bleed that prevents use of anticoagulation. what is the treatment for their PE?

Answer 22

IVC filter

Question 23

what are the WHO pulm HTN classifications

Answer 23

class 1: idiopathic, hereditary, drug induced, cong HD, CTD, or HIV associated
class 2: d/t left sided Heart disease
class 3: d/t lung disease/hypoxia
class 4: d/t chronic thromboembolic pulm HTN
class 5: multiple causes (ex. sarcoidosis)

Question 24

cyanosis, hepatomegaly, JVD and accentuated P2 sound.

Answer 24

PE findings of pulm HTN

also see:
tricusoid regurg murmur
3rd kentucky heart sound
lower extremity edema

Question 25

what pulmonary capillary wedge pressure is indicative of left sided heart disease

Answer 25

16 or more

confirm with left heart cath!

Question 26

a drop of mPAP of 10-40mmHg after injection of vasodilator

Answer 26

vasodilator response

Question 27

CCB such as high dose diltiazem and nifedipine used as treatment

Answer 27

pulmonary HTN NYHA class 1-3 with vasoreactive disease

Question 28

produced in the cells that line the heart and lungs; when released results in vasoconstriction

Answer 28

endothelin

Question 29

sidenafil and tadalafil are what types of meds

Answer 29

PDE 5 inhibitors

Question 30

monotherapy is considered for treatment

Answer 30

non-vasoreactive NYHA stage 1 pulm HTN

Question 31

combination therapy of endothelin antgonists and PDE5 inhibitors

add guanylate cyclase stimulators or oral prostacyclin receptor agonists if uncontrolled

Answer 31

management for non vasoreactive NYHA stage 2/3 pulm HTN

Question 32

Add on parenteral prostanoid to oral combination therapy

Answer 32

non-vasoreactive NYHA stage IV pulm HTN