Flashcards in Week 219 - Haemoptysis (PE) Deck (26)
Name the 3 parts of Virchow's Triad for thrombosis
- Blood stasis
- Vessel injury
Name 3 ways in which a vessel may be injured to increase risk of thrombosis
- Atherosclerotic plaque formation
- compression from tumour
- Vessel trauma
List the main symptoms of DVT
Calf tenderness/pain; Calf swelling; Heat; Redness; difficulty of pain on dorsiflexion; none
What is Homan's sign?
An indication of DVT, pain or difficulty on dorsiflexion
What is Well's Score?
A probability calculator for the likelihood of a DVT
List the risk factors for DVT
Malignancy (within last 6 months); Immobility; Surgery (particularly on leg or pelvis); previous DVT; hypercoagulable states e.g. thrombophilia; pregnancy; FHx; long-hall flights; Synthetic Oestrogen; Age; Obesity
What is the first investigation you should do to detect DVT?
Doppler Ultrasound (CT rarely used!)
What is a D-dimer test?
A test of the level of D-dimer in the blood. D-dimer is a breakdown product of cross-linked fibrin - it is elevated in thromboembolism.
What do D-dimer results tell you?
A negative result virtually excludes DVT. A positive result requires further investigation as D-dimer is also elevated in: post surgery, trauma, liver / renal disease, pregnancy, cancer, heart diseases etc.
What is the management for DVT?
LMWH (enoxaparin/heparin) until Dx confirmed; Doppler USS next day; Cont. heparin until INR ~2.5; then Warfarin 3/12 if clear cause - if no clear cause 6/12
Why is pulmonary infarction not an invariable consequence of PE?
Due to the dual blood supply to the lung parenchyma: bronchial and pulmonary
What causes the 10% of haemoptysis in PE
Necrosis of lung parenchyma due to pulmonary infarction
What are the principle symptoms of PE?
Acute/subacute SOB; pleuritic chest pain; dizziness; syncope; restlessness/anxiety; haemoptysis (~10%)
What are the cardinal SIGNS of PE?
Dyspnoea; Tachypnoea; Pleuritic pain
List other signs that frequently present with PE
Tachycardia; Cyanosis; Pyrexia; AF; signs of recent surgery; raised JVP; Hypotension; Pleural rub; Loud/Widely split 2nd heart sound (P2)
Describe the main difference between a normal clot and a pathological clot?
A normal clot is porous to allow plasmin in to breakdown the fibrin mesh. A pathological clot (e.g. that seen in a Pt with malignancy) is a much tighter mesh of fibrin making it difficult for plasmin to break down
What is atelectasis?
Where one or more areas of the lung don't inflate properly
What might you see on a CXR of someone with PE?
Nothing; linear shadow; Peripheral wedge;small effusion; elevated diaphragm; Paucity of vessels; Small cavity/abscess
What changes might you see on an ECG with PE?
Sinus tachycardia; ST / T wave changes in V1-V3; Right axis deviation; S1, Q3, T3 (large S wave in lead I, large Q wave in lead III and T wave inversion in lead III)
What is considered the gold standard for imaging investigation of PE?
CT pulmonary angiography (sensitivity >95%)
What is the reason for often seeing Rt axis deviation on an ECG with PE?
Enlarge right side of heart due to increased pressure
What imaging might a woman opt for over a CTPA in the investigation of PE and why?
a Ventilation / Perfusion scan - less radiation, effective on those without previous lung disease. Cost effective though low, med, high prob diff to interpret
What other investigation might be helpful with massive PE prior to thrombolysis?
ECHO - may show: cardiac compromise; RV overload (cannot exclude small PE)
What is a Pesi Score?
Predicts 30 day outcome of Pts with PE
What is the immediate management for PE?
High flow O2; IV fluids; analgesia (for pleuritic pain)
Consider unfractionated heparin - in unsure give! clexane whilst investigate; thrombolysis if early (12-24 hours)