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Flashcards in pulmonary embolism and hypertension Deck (20)
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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?

- thrombophilia
- contraceptive pill
- pregnancy
- pelvic obstruction eg uterus, ovary
- trauma
- surgery
- immobility eg bed rest, long haul flights
- malignancy
- obesity
- 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
- troponin
- 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?

- thrombolysis


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)


how do you investigate pulmonary hypertension?

-ECG = rhythm, axis, p pulmonale, right bundle branch block
- CXR = cardiomegaly
- SAO2 and ABG
- pulmonary function with DLCO
- echo