Pulmonary embolism

• Other than PE, what are the other causes of raised D-dimer?


  Liver disease

  Inflammation

  Malignancy

  Pregnancy

  Trauma

  Recent surgery
• What is a massive PE?


  When there is haemodynamic instability
• Pathophys of PE


  
  

  Thrombus formation (due to Virchow’s triad → venous stasis) → thrombus dislodgment → emboli travel through venous system → emboli pass through R heart & into pulmonary arterial system → becomes lodged in pulmonary arterial system → obstruction of blood flow → increased pulmonary vascular resistance → hypoxia, ischaemia & inflammation in affected lung parenchyma → pleuritic chest pain & SOB

  Large or multiple emboli can lead to RV strain & RHF (systemic hypotension, shock & sudden cardiac death)
• What are the signs & symptoms of PE?


  SOB

  Pleuritic chest pain

  Cough

  Haemoptysis

  Cyanosis

  Signs of DVT

  Positive Wells score

  Hypoxaemia

  Tachycardia

  Tachypnoea

  Loud S2

  Fever
• What are the RFs of PE?


  DVT

  Recent surgery (last 2 months)

  Significant immobility

  Previous VTE

  Active cancer

  Thrombotic disorders (antiphospholipid antibody syndrome)

  Recent trauma or lower limb fracture

  Recent MI

  Increasing age

  FHx of VTE

  Pregnancy/postnatal period

  COC use

  Smoking

  Indwelling central vein catheter

  Long-duration travel

  Obesity
• What are the Inx for PE?


  Obs

  Full Hx & examination

  ECG

  Well's score for PE

  Bloods (FBC, U&Es, LFTs, CRP, D-dimer, Coag, ABG (if hypoxic))

  CXR

  CTPA

  V/Q scan

  Echo (if cannot do CTPA, haemodynamically unstable pts)

  Lower limb compression USS
• What may an ECG show in PE?


  Textbook changes = S1Q3T3

  • large S wave in lead I, a large Q wave in lead III and an inverted T wave in lead III

  RBBB or right axis deviation

  Sinus tachycardia
• What is the most specific Inx for PE?


  CTPA

  Can visualise thrombus in pulmonary artery
• Wells score for PE


  Clinical signs & symptoms of DVT = +3

  Alternative Dx less likely than PE = +3

  HR > 100 = +1.5

  Immobilisation (> 3 days) or surgery (past 4 weeks) = +1.5

  Previous DVT/PE = +1.5

  Haemoptysis = +1

  Malignancy = +1

  Results

  > 4 = PE likely

  4 or less = PE unlikely
• Fill in the blanks

  A) CTPA

  B) anticoagulation

  C) CTPA

  D) CTPA

  E) CTPA

  F) PE

  G) Proximal leg USS

  H) D-dimer

  I) 4 hours

  J) anticoagulation

  K) D-dimer

  L) D-dimer

  M) D-dimer

  N) diagnosis

  O) stop

  P) anticoagulation

  
• What are the DDx of PE?


  ACS

  CAP

  Acute bronchitis

  Exacerbation of COPD/ABG/CHF

  Pericarditis

  Cardiac tamponade

  PTX

  Panic disorder
• How long is treatment for a PE with an obvious RF?


  3 months
• How long is treatment for a PE without an obvious RF?


  6 months
• What is the treatment of PE (haemodynamically stable)?


  Anticoagulation (1st line) -> apixaban/rivaroxaban

  PLUS risk assessment (PESI score)
• What is the treatment of PE (haemodynamically unstable)?

  UF heparin + thrombolysis (alteplase) (1st line)

  Several hours after end of thrombolysis (thrombolysis lasts 2 hours?) → switch to anticoagulant (apixaban/rivaroxaban) + UFH

  Consider vasoactive drug (adrenaline/dobutamine) -> if systolic BP < 90 after thrombolysis

  Consider surgical embolectomy/percutaneous catheter-directed treatment (if thrombolysis fails)
• What is PESI?


  PE Severity Index

  Used to determine mortality and long term morbidity
• Who should PESI scoring not be used in?


  Pts with hypotension/shock

  Pregnant women

  Pts with active cancer (use HESTIA score)