Deep Venous Thrombosis & Pulmonary Embolus

Front 1

If you suspect a PE, what should you do before further tests?

Back 1

Start IV heparin!

Front 2

Diagnostic Test for PE?

Back 2

VQ Lung Scan

Front 3

So PE's can present very differently...what are three factors that dictate to a large degree how they present?

Back 3

Size of Clot
Degree of Arterial Obstruction
Comorbid Conditions

Front 4

General types of conditions that may precipitate venous thrombosis?

Back 4

Conditions that inc venous stasis
Conditions the cause endothelial damage
Sub clinical hypercoagulable states

Front 5

General Effects of PE's?

Back 5

Inc Pulmonary Vascular Resistance
Impaired Gas Exchange
Alveolar Hyperventilation
Inc Airway Resistance
Dec Pulmonary Compliance

Front 6

Usual Cause of Death in PE?

Back 6

Right Ventricular Dysfunction?

Front 7

Typical Clinical Findings w/ PE?

Back 7

Unexplained Dyspnea
Chest pain
Tachycardia
Syncope

Front 8

Rx for Massive PE?

Back 8

Thrombolysis
Embolectomy

Front 9

Elements of Massive PE Syndrome?

Back 9

Systemic Arterial Hypotension
Cardiogenic Shock
At least half of pulmonary vascular affected
Bilateral Clot
Dyspnea
Transient Cyanosis
Often w/o chest pain
Anatomically widespread thromboembolism

Front 10

Moderate to Large PE Syndrome elements?

Back 10

RV Hypokinesis on echo
Normal systemic pressure
Elevated Troponin/BNP
1/3 of vascular affected
Risk of recurrence

Front 11

Rx for moderate to large PE?

Back 11

Controversial
Toss up between anticoagulation and thrombolysis/embolectomy

Front 12

Small to Moderate PE Syndrome elements?

Back 12

Normal Right Heart Fxn
Normal Systemic Pressure
No troponin or pro-BNP release

Front 13

Rx for small to moderate PE?

Back 13

anticoagulation

Front 14

Pulmonary Infarction syndrome?

Back 14

Usually small PE
Really Painful
Maybe Hemoptysis
Maybe associated w/ larger PE
Fever
Leukocytosis
Elevated ESR

Front 15

when do the sx's of infarction occur in relation to embolism?

Back 15

3-7 days

Front 16

Prognosis of moderate to large PE?

Back 16

most survive

Front 17

Most frequent symptom and sign of PE?

Back 17

symptom: dyspnea
sign: tachypnea

Front 18

4 kicker Sx's for Massive PE?

Back 18

dyspnea
syncope
hypotension
cyanosis

Front 19

3 kickers for distal, small PE?

Back 19

pleuritic pain
cough
hemoptysis

Front 20

Problem w/ PE in young, healthy pts?

Back 20

may simply appear anxious w/ dyspnea on moderate exertion

no other "classic" sx's

Front 21

Typical Sx's w/ elderly PE pts?

Back 21

vague chest pain
Tachypneic and Tachycardic
Maybe hypotension, cyanosis, RHF

Front 22

Non-imaging Diagnostic Tools for PE?

Back 22

Plasma D-Dimer ELISA level
ABG
ECG

Front 23

When is D-Dimer indicative of PE?

Back 23

D-Dimer is >500ng/mL in more than 90% of PE pts

Front 24

Key to usefulness of D-Dimer level?

Back 24

It's negative predictive value. D-Dimer is also raised w/ MI's, sepsis, etc, but if its not raised its not PE

Front 25

Cause of elevated D-Dimer?

Back 25

Plasmin's breakdown of fibrin
Endogenous thrombolysis (clinically ineffective)

Front 26

ABG findings w/ PE?

Back 26

pO2 and pCO2 decreased
little diagnostic utility

Front 27

ECG findings w/ PE?

Back 27

Sinus Tach or new onset A-Fib or flutter
S wave in 1, Q in III, inverted T in III
Right axis deviation
T inversion in V1-V4

Front 28

Noninvasive Imaging Modalities for PE?

Back 28

CXR
Venous Ultrasonography
Contrast CT
Lung Scan
Echo

Front 29

Other invasive imaging modality?

Back 29

Pulmonary Angiography

Front 30

CXR findings w/ PE?

Back 30

Normal or near-normal CXR
Focal Oligemia (westermark's sign)
Peripheral wedge-shaped density (hampton's hump)
Enlarged Right Descending Pulmonary Artery (palla's sign)

Front 31

Venous Ultrasonography findings w/ PE?

Back 31

Loss of Vein Compressibility
Not super good test: negative in 50% of PE pts

Front 32

Which imaging study is the new boss? old boss?

Back 32

Pulm angiography is getting phased out by Contrast CT

Front 33

One reason why contrast CT is so good?

Back 33

it establishes alternative dx (pneumonia, emphysema, etc)

Front 34

Usefulness of Lung Scan and Echo?

Back 34

bad...50/50 shot or worse

Front 35

Why is Echo good?

Back 35

RV dysfxn
Other heart problems

Front 36

What is the most sensitive imaging study?

Back 36

Angiography

Front 37

Primary PE Therapy?

Back 37

Clot dissolution w/ thrombolysis and embolectomy

Front 38

Secondary Prevention for PE?

Back 38

Anticoagulation w/ heparin and warfarin or installing IVC filter

Front 39

who are the high risk PE pts?

Back 39

Hemodynamic instability
RV dysfxn
Elevated Troponin due to RV microinfarction