Pulmonary Embolism 2008

Front 1

What test should be performed in the low to moderate probability of pulmonary embolism in a patient?

Back 1

D-dimer

Front 2

How is a D-dimer test helpful?

Back 2

A d-dimer level below 0.5 mg/L reliably rules out the presence of circulating fibrin and this essentially rules out a diagnosis of venous thromboembolism.

Front 3

In what patient population is a d-dimer test not helpful?

Back 3

A D-dimer test should not be used in patients with a high clinical probability of pulmonary embolism, since the negative predictive value of this test is low for these patients.

Front 4

What is the alternative to CT angiography if the patient cannot tolerate contrast dye?

Back 4

A ventilation perfusion lung scan is the alternative.

Front 5

What single imaging study is used in most cases of suspected pulmonary embolism?

Back 5

CT angiography.

Front 6

In the older child, proximal and distal compression ultrasonographic examination can improve the sensitivity of what imaging study?

Back 6

CT angiography

Front 7

What is the deficiency of MRI scanning for pulmonary embolism?

Back 7

Currently MRI does not have adequate sensitivity for imaging distal branches of the pulmonary arteries.

Front 8

For patients with suspected pulmonary embolism who presents with hypotension or shock, what bedside study could be performed as an alternative to CT angiography?

Back 8

Echocardiography.

Front 9

What is the advantage of low molecular weight heparin for the treatment of pulmonary embolism?

Back 9

Low molecular weight heparin is easier to administer and has a lower incidence of heparin-induced thrombocytopenia. It has a similar safety profile as unfractionated heparin.

Front 10

What is the recommended initial dose of unfractionated heparin for pulmonary embolism?

Back 10

The initial dose is 80 international units/kg of body weight as an intravenous bolus followed by continuous infusion at the rate of 18 international units/kg/hr.

Front 11

What parameters are followed to adjust the infusion rate of unfractionated heparin?

Back 11

The activated PTT is maintained between 1.5 and 2.5 times control. Factor X a inhibition is maintained between 0.3 and 0.7 international units/ML.

Front 12

How long is heparin utilized before transitioning to an oral anticoagulant (vitamin K antagonist)?

Back 12

Five to 6 days of heparin followed by Coumadin.

Front 13

What target laboratory is utilized for Coumadin therapy?

Back 13

The international normalized ratio (INR) of 2.0 to 3.0 for two consecutive days.

Front 14

What is the clearest indication for thrombolysis and pulmonary embolism?

Back 14

Thrombolyzes is indicated in the case of patients with pulmonary embolism who have arterial hypotension or are in shock.

Front 15

Is there any advantage to infusing a thrombolytic agent directly into the pulmonary artery as opposed to administration systemically?

Back 15

Direct infusion of thrombolytic agents through a catheter in the pulmonary artery has not been shown to offer any advantages over systemic intravenous thrombolyzes.

Front 16

What are the absolute contraindications to thrombolysis?

Back 16

A history of hemorrhagic stroke or stroke of unknown origin, ischemic stroke and previous scans, central nervous system neoplasms, major trauma, surgery, or head injury in the previous 3 weeks.

Front 17

What are the relative contraindications to thrombolysis?

Back 17

Transient ischemic attacks in the previous 6 months, oral anticoagulation, pregnancy or postpartum week number one, noncompressible puncture site, traumatic resuscitation, refractory hypertension, advanced liver disease, infective endocarditis, active peptic ulcer disease.

Front 18

What is the dose of TPA?

Back 18

For the adults the dose is 100 mg over a two-hour period.

Front 19

Can heparin be administered with TPA?

Back 19

Unfractionated heparin can be given during TPA administration. Low molecular weight heparin as of yet have not been tested in combination with thrombolyzes in patients with pulmonary embolism.

Front 20

What are the surgical indications for pulmonary embolism?

Back 20

Patients who have free-floating thrombi in the right atrium or ventricle and those with impending paradoxical embolism through patent foramen.

Front 21

Non–high-risk pulmonary embolism identifies an
embolism in patients who have normal blood pressure
on presentation. What is the treatment for these patients?

Back 21

Initiate anticoagulant treatment with unfractionated or low molecular weight heparin while awaiting the results of further diagnostic tests.

Front 22

Intermediate-risk (submassive) pulmonary embolism
identifies an embolism in a subgroup of
normotensive patients who may have an elevated
risk of death or serious complications if they present
with right ventricular dysfunction or injury to
the myocardium as a result of pressure overload. What is the treatment for these patients?

Back 22

Currently, low-molecular-weight heparin or fondaparinux
is considered to be adequate treatment
for most normotensive patients with intermediate-
risk pulmonary embolism (Table 3). However,
early thrombolysis may be considered for selected
patients who have a high risk of early death (due,
for example, to preexisting heart failure or respiratory
failure) and for whom thrombolytic agents
are not contraindicated.

Front 23

High-risk (massive) pulmonary embolism is defined
by the presence of cardiogenic shock, persistent
arterial hypotension, or both. What is the treatment for these patients?

Back 23

Weight adjusted bolus of unfractionated heparin should be administered immediately. If the diagnosis of massive pulmonary embolism is confirmed thrombolytic agents should be administered without delay. If thrombolyzes is absolutely contraindicated or has failed surgical embolectomy or catheter-based thrombus fragmentation or suction is a valuable alternative.