Flashcards in pulmonary embolism and hypertension Deck (20)
what are the features of a proximal (ileo-femoral) DVT?
- more likely to embolise
- more likely to lead to chronic venous insufficiency and venous leg ulcers
what are the features of a distal (polpiteal) DVT?
- least likely to embolise
how do you investigate a DVT?
- ultrasound doppler leg scan (1st line) = non invasive, exclude popliteal cyst, pelvic mass
- CT scan = ileo-fermoral veins, IVC and pelvis
what is the clinical presentation of a large PE?
cardiovascular shock, low BP, central cyanosis, sudden death
what is the clinical presentation of a medium PE?
pleuritic pain, haemoptysis, breathlessness
what is the clinical presentation of a small PE?
progressive dyspnoea, pulmonary hypertension, right heart failure
what are the risk factors for DVT and PE?
- contraceptive pill
- pelvic obstruction eg uterus, ovary
- immobility eg bed rest, long haul flights
- pulmonary hypertension
how do you prevent a DVT?
- early post-op mobilisation
- TED compression stockings
- calf muscles exercise
- direct oral anticoagulant medication
how do you diagnose a PE?
- tachycardia, tachypnoea, cyanosis, fever, low BP, crackles, rub, plaural effusion
- type 1 resp failure
- CXR = consolidation
- prediction scores
what is the diagnosis and investigation of a PE?
- pulmonary embolism severity index (PESI)
- ECG = acute right heart strain pattern
- D-dimers usually raised
- isotope lung scan
- CT pulmonary angiogram = to image pulmonary artery filing defect
- leg and pelvic ultrasound
- echocardiogram = to measure pulmonary artery pressure and right ventricular size
what to do for a PE and when?
- high risk of PE = CTPA
- ambulatory setting with low risk = V/Q or CTPA
- pregnancy = ultrasound
where are patients best managed?
- low risk/ low PESI = ambulatory pathway and then home
- high risk with cardiovascular compromise who may require thombolysis = BP monitoring and HDU
- intermediate high risk = ward or HDU
how do you treat DVT and PE?
- anticoagulation prevents vlot
- therapeutic dose of S/C low molecular weight heparin
- high suspicion = empirical treatment
- low suspicion = wait
- LMWH - once daily injection
- start warfrin simultaneously
- antagonises vit K dependent prothrombin
- after 3-5 days stop heparin when INR > 2
what are the target ranges for warfarin with INR?
- 2-3 for first event
- 3 or more for recurrent events
- 3.5 if recurrent DVT/PE whilst on earfarin
how do you treat PE only?
what is pulmonary hypertension?
- high flow, low pressure system
- high mean pulmonary arterial pressure eg > 25 mmHg instead of 12-20 mmHg
- measured with right heart catheter
- systemic pulmonary arterial pressure can be estimated with ECHO doppler
what are the causes of pulmonary hypertension?
- pulmonary venous hypertension (left heart disease)
- pulmonary arterial hypertension (PAH)
- primary pulmonary hypertension eg hypoxia
what is cor pulmonale?
- right heart disease secondary to lung disease
- fluid retention due to hypopxia +/- right heart failure
- can complicate COPD, fibrotic lung disease, chronic PE, chronic ventilatory failure eg obesity
what are the clinical sign of pulmonary hypertension?
- central cyanosis if hypoxic
- dependent oedema
- raised JVP with V waves
- right ventricular heave at left parasternal edge
- murmur of tricuspid regurgitation
- load P2
- enlarged liver (pulsatile)