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Year 3 > Week One - Case Two > Flashcards

Week One - Case Two Flashcards

1
Q

what is a pulmonary embolism most common secondary to

A

a VTE from another source that becomes dislodged, flows via bloodstream, through the right side of the heart and gets lodged into the pulmonary circulation

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2
Q

what is the mortality rate of PE with VTE if there is no haemodynamic instability

A

<5%

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3
Q

what is the mortality rate of a PE with VTE if shock is present

A

30%

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4
Q

what is the mortality rate of a PE with VTE if cardiac arrest happens

A

70%

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5
Q

what are the risk factors for a PE

A

age

Malignancy

Infection

Family history

Immobility
Bed rest >24 hours
Immobility >48 hours
Plaster of Paris over limbs

pregnancy - oestrogen (4 weeks after birth)

Previous DVT

Trauma or surgery

Dehydration

Smoking

Congestive heart failure

Antithrombin and protein C
deficiency

Obesity

Varicose veins

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6
Q

what are the signs of a PE

A

Pyrexia

Cyanosis

Tachypnoea

Tachycardia

Hypotension

Raised JVP

Pleural rub

Pleural effusion

Look for signs that could indicate a cause – e.g. DVT, recent surgery, air travel –

Atrial fibrillation (rare)

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7
Q

what percentage of people have tachypnoea with a PE

A

90% of patients have RR>16

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8
Q

what percentage of people have tachycardia with a PE

A

45%

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9
Q

what percentage of people have hypotension with a PE

A

25%

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10
Q

what are the most common symptoms of a PE

A

Pleuritic chest pain (pain worse on inspiration) –75% of patients

Breathlessness –85% of patients

Cough –50% of patients

Haemoptysis – as a result of pulmonary infarct –30% of patients

Dizziness / pre-syncope –15% of patients

Syncope (loss of consciousness/fainting) –15% of patients

Non-pleuritic chest pain – 15% of patients

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11
Q

what is the first symptom to occur

A

shortness of breath occurs within seconds and pain develops later

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12
Q

what is the PERC score used for diagnosis

A

stands for pulmonary embolism rule-out criteria

it is useful to rule out PE in low risk patients

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13
Q

what happens if patient’s PERC score is 0

A

there is less than 2% chance of PE

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14
Q

how is PERC score scored

A

Each factor below gives a score of 1. All factors must be negative for a negative PERC score. Any positive factor results in the need for further work up (move onto the Well’s Score)

Age >50
HR >100
SaO2 on room air <95%
Unilateral leg swelling
Haemoptysis
Recent surgery or trauma
Previous PE or DVT
Exogenous Oestrogen

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15
Q

what is the Well’s Score for PE

A

this can stratify patients as low risk or high risk.

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16
Q

what should happen with low and high risk patients

A

with high risk patients you should proceed straight to imaging

in low risk patients you should consider a D dimer test

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17
Q

look up the scores used in the Wells Score

A
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18
Q

what is the traditional interpretation used of Well’s Score

A

Score >6.0 — High (probability 59%)

Score 2.0 to 6.0 — Moderate (probability 29%)

Score <2.0 — Low (probability 15%)

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19
Q

what is the alternative interpretation of the Well’s Score

A

Score > 4 — PE likely. Consider diagnostic imaging.

Score 4 or less — PE unlikely. Consider D-dimer to rule out PE.

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20
Q

what is D dimer

A

a fibrin deviation product - and as such, levels are raised by the presence of a blood clot in the circulation

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21
Q

what does a negative D-dimer plus a low Well’s score mean

A

that PE or DVT is extremely unlikely

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22
Q

when should a D dimer only be used

A

should only be used as a rule out test in low probability cases - based on the Well’s scoreb

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23
Q

what does a positive D-dimer test in a low probability case indicate

A

the need for further investigation

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24
Q

what should you do with a high probability case

A

skip the D dimer and go straight to imaging

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25
Q

what, apart from a PE results in a positive D dimer

A

any factor that causes inflammation will also result in a raised D-dimer

26
Q

when is a D-dimer test not appropriate as an investigation approach

A

if the patient recently had cellulitis or another infection

27
Q

what happens with age to the D dimer value

A

D dimer also rises with age.

28
Q

what is the traditional reference range for D dimer

A

normal <0.5

Example of age adjusted:

Age <50 – normal <0.50

Age >50 – normal range is <0.50PLUS0.1 for every decade of life over the age of 50, e.g.:
Age 60 – normal <0.60
Age 70 – normal <0.70

29
Q

what other factors may cause an increased D dimer

A

Other factors that caused an increased D-Dimer includeliver disease, high rheumatoid factor, malignancy, trauma, pregnancy and recent surgery.

30
Q

what would a CXR normally look like in PE

A

often be normal
the main reason it is performed is to exclude other causes

31
Q

what are the potential, rare findings on a PE CXR

A

the CXR may show pulmonary oedema signs such as raised hemidiaphragm.

May also show atelectasis - this is little areas of collapsed lung

32
Q

why does this occur

A

because there is a loss of blood to some areas - a conservative mechanism

33
Q

what raises the suspicion of a PE

A

if the CXR is normal but the patient is breathless

34
Q

what happens if the CXR has bilateral changes, but the patient only has unilateral pain

A

this also raises the suspicion of a PE

35
Q

what are the most common findings in ECG

A

T wave inversion and sinus tachycardia

36
Q

what can large emboli cause to show on an ECG

A

cause right heart strain, which will result in the ‘classical’ S1Q3T3 pattern

37
Q

what percentage of PE patents will have ECG changes

A

80%

38
Q

what its the classical S1Q3T3 pattern

A

S waves presentin lead I
Q waves present in lead III
T wave inversion in lead III

39
Q

what is a CTPA

A

a CT-pulmonary angiogram

CT with contrast, assessing the pulmonary blood vessels.

40
Q

what is its main use

A

the diagnosis of a PE

41
Q

what is the typical diagnostic scan used for a PE

A

a CTPA

42
Q

are VQ or CTPA scans more accurate in diagnosing PE

A

CTPA -VQ scans are much less accurate

the result of a VQ scan is usually given as a risk probability - high risk, intermediate risk or low risk

43
Q

when would a VQ scan be used instead

A

as an alternative in young females, or pregnant females

44
Q

what do the results of an ABG show

A

02 may be low

C02 may often be normal or low

45
Q

why is there low C02

A

the patient is hyperventilating

46
Q

what is common seen in patients with a massive PE and cardiovascular collapse

A

metabolic acidosis

47
Q

in what percentage of PE patients is troponin raise

A

20-40% as a result of the extra stress and stretch placed on the right ventricle with PE patients (due to increased pulmonary arterial pressure)

higher troponin has been associated with a worse prognosis

48
Q

what should a patient with signs of right heart strain and haemodynamic instability be considered for

A

thrombolysis

49
Q

what is used for thromboylsis

A

50mg alteplase - long list of contraindications

50
Q

what is a saddle PE

A

a PE sitting at the major bifurcation of the pulmonary veins

51
Q

what is the other main treatment

A

anticoagulation

52
Q

what can this be done with

A

warfarin, or a NOAC

53
Q

what is an example of an NOAC

A

rivaroxaban

54
Q

what is most favourable

A

NOAC as it dos not require monitoring and does not require the use of heparin at the start of the treatment period

55
Q

what is an example of warfarin treatment

A

Anticoagulate with LMWH – e.g. dalteparin 200u/Kg/24hrs. The max dose is 18,000.

At the same time start oral warfarin 10mg

Stop the heparin when the INR is >2, and continue warfarin for a minimum of 3 months, aiming for an INR of 2-3.

56
Q

when is a vena cava filter considered

A

in patients with recurrent thrombus despite anticoagulation, - but remember that implanting a filter without adequate anticoagulation will increase the risk of thrombus

57
Q

what is the minimum amount of time for continuation of anticoagulant therapy

A

at the very minimum 6 weeks

58
Q

what about those with an identifiable and reversible risk factor

A

3 months

59
Q

what about those with idiopathic disease

A

6 months

60
Q
A
61
Q
A

Year 3 (63 decks)

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