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32 Cards in this Set
- Front
- Back
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Epidemiology:
650,000 pts/year 3rd leading cause of death in US >200,000 deaths/year -... die within first hour -16,000 die despite appropriate medical tx >... % are dx at autopsy Under age 50: males>females #... cause of nonsurgical peripartum death |
1/3
50 1 |
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If thrombus is in the venous system, it ends up in the ... vasculature.
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pulmonary
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... is the largest source of thromboembolism.
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Venothromboembolism
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When a large piece of thrombus is floating in the stream, it’s known as an ....
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emboli
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Formation of thrombus:
Begins at ... sinus ... propagation begins in minutes to hours Risk of embolization greatest within ... Rare for thrombus below ... to cause PE |
valve
Proximal 1st week knee |
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Pathophysiology of PE:
Mechanical obstruction to pulmonary vasculature Release of ... and ... mediators Usually multiple emboli and bilateral involvement |
vasoactive and bronchoactive
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Pathophysiology of PE:
Mechanical obstruction in pulmonary vascular bed Focal areas of hypoperfusion to lung in areas that are ventilated creates ... mismatch ... results which further increases pulmonary arterial pressure Significantly increases RV ... |
VQ (ventilation perfusion)
Vasoconstriction afterload |
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..., or right-sided heart failure, is an enlargement of the right ventricle due to high blood pressure in the lungs usually caused by lung disease.
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Cor pulmonale
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Cor Pulmonale:
-Altered structure and function of RV caused by disorder of respiratory system -Can be chronic or acute -Sudden increase on R ventricular ... with pulmonary embolus causes ... cor pulmonale |
afterload
acute |
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Cor pulmonale: R heart ... walled: better for volume pumping than ... pumping
Handles increased ... better than increased ... Will ... easily and develop problems with contraction |
thin
pressure preload afterload dilate |
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Pathophysiology:
... activation in lung causes release of vasoactive and bronchoactive substances: -Substance P, bradykinin, prostaglandin -Pulmonary aa. ... is major effect -... mismatch develops -Decreases lung ..., increases R heart afterload |
Platelet
vasoconstriction VQ compliance |
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What is Virchow’s triad?
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Venous stasis
Hypercoagulability Endothelial damage |
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Predisposing factors:
Same as for DVT: ... Triad -Venous stasis -Hypercoagulability -Endothelial damage IV drug use predisposes to ... emboli |
Virchow’s
septic |
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What are the 3 most frequent findings in PE?
-Less than 20% of cases have these 3 |
Dyspnea
Hemoptysis Pleuritic chest pain (pain upon deep inspiration) |
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PE presentation: Signs
... – 92% occurance ... – 43% |
tachypnea (respirations > 16/min)
low grade fever (temp > 37.8) |
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Clinically useful signs/sx:
... ... ... -10-15% present with syncope/near syncope -... in elderly -Generalized seizure -... present in >50% (hypoxia will stimulate this) |
Chest pain (usually pleuritic)
Dyspnea Tachypnea (RR>16) AMS (altered mental status) Anxiety |
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Physical exam findings:
R heart failure may be present -... -Increased pulmonic valve sound with split ... -Present with ... PE |
JVD
S2 massive |
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Massive PE:
... – leads to decreased CO Hypoxemia 40-50% ... of pulmonary arteries 5% of all PE are massive 40% ... |
Hypotension
obstruction mortality |
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Submassive PE:
-... hemodynamics -... improves with supplemental O2 -2% ... if treated appropriately |
Normal
Hypoxemia mortality |
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Diagnosis:
-EKG CXR– almost always nonspecific and vague -... – an increased A-a gradient goes along w/ a PE -US LE for DVT -... chest- PE protocol. Use contrast. -... – Gold standard |
ABG
CT Pulmonary angiogram |
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Diagnosis: CXR findings
... normal in 1/3 pts with PE Will eventually develop abnormalities -Infiltrate -Atelectasis -Elevated hemidiaphragm with pleural effusion -... –rare (wedge-shaped pleural infiltrate) -... –rare (engorged pulmonary aa proximally) Mostly useful to exclude other pathology: -PTHx, pneumonia |
Initially
Hampton’s hump Westermark sign |
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look at slide 31-32
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ok
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Diagnosis: ABG
Hypoxemia -... to size of PE ... A-a gradient |
not relative
Increased |
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Diagnosis: Laboratory Testing
Dimerized plasmin fragment D (...) ... with PE -Sensitive but not specific to PE -If it’s negative, it most likely ...; if it’s positive, it ... Useful to exclude presence of PE if low D-dimer |
D-dimer
Elevated rules out a PE does not mean that you have a PE (do another test) |
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Diagnosis: Imaging Studies
If US negative for DVT with high suspicion of LE DVT, treat ... (heparin, LMWH) then repeat study in ... Most will propagate by that time and be detected Embolism is rare from ... prior to proximal propagation Serial exams and repeat study |
prophylactically
1 week below the knee |
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Diagnosis: VQ scan
Reliable only at ...: -Normal -High probability Must combine with ... suspicion -No useful diagnostic algorithm to quantify clinical suspicion |
extremes
clinical |
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Diagnosis: ...
Gold standard If negative, reliably excludes dx of PE 0.5% mortality; 4% morbidity |
Pulmonary Angiography
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Medications: Anticoagulant therapy
... -***Immediate action*** -Interferes with clotting factors and increased PTT -5000 Unit bolus or 80 Units/kg bolus -Follow with 1280 Unit/hr gtt or 18 Units/kg/hr gtt Check PTT at 6 hr intervals Aim for PTT=50-90 |
IV heparin
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Medications: Anticoagulant therapy
... -***Takes time to become effective*** -Initial hypercoagulation effects -***Begin after 24 hr ... therapy*** -5-10mg PO daily -Follow PT/INR to monitor effects -Goal INR=2-3 -Overlap with ... for 4 days Continue ... for 3mos |
Warfarin
heparin heparin warfarin |
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Medications: Anticoagulant therapy
... -Shown to be as safe and effective as heparin -Used SQ so can be used as outpatient therapy -Begin warfarin in conjunction as with heparin |
Low-molecular-weight-heparin (Lovenox)
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Medications: Thrombolytic tx
-For ... PE -If ... dysfunction present -Urokinase -Streptokinase -Recombinant tissue plasminogen activator (rTPA) –fastest -Later switch to heparin and warfarin treatment |
massive
RV |
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Tx: ...
-For recurrent PE or if pt has contraindication to warfarin therapy -Umbrella into inferior vena cava |
Greenfield filter
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