What steps are necessary before investigating a chest pain as a potential PE or PHTN?
1. Rule out cardiac disease
2. Rule out other causes
3. Rule out infection
What is the difference between a thrombus and an embolus?
Emboli are foreign bodies that travel in the blood stream.
Thrombi are locally formed clots.
What types of things can be responsible for embolism?
Air, Fat, Cholesterol, Platelet aggregates, clots, etc.
Any foreign body that travels in the blood stream can be considered an embolus.
What vessels fill the right side of the heart?
Superior and Inferior Vena Cava
Where do PE's come from?
No Sxs to Sudden Death
Localized pleuritic chest pain, with or without dyspnea.
Severe dyspnea with little chest pain
Pleuritic chest pain, cough, hemoptysis.
Signs of DVT may or may not be present.
The scoring system for suspected DVT can be used to assess likelihood of an embolus from a deep vein. What score indicates that a DVT is likely?
2 or more.
There is a scoring system in the presentation for assessing likelihood of pulmonary embolism. What score indicates a likely PE?
4 or more
Using the scoring system from the presentation, when someone gets a score of less than 4 on the PE test, what is the next step in their evaluation?
D-dimer test, and DVT safely ruled out.
Using the presentation's PE test, those with a high risk for PE need further workup. What should that workup look like?
Pulmonary Angiogram (gold standard)
Spiral CT of the chest with contrast.
Ventilation perfusion scan
Venous doppler of legs
ABG (arterial blood gasses)
Always remember to check the upper extremities in the case of PE, what ratio of emboli do not originate in the leg?
Some risk factors for clotting:
slow or impeded circulation (nice environment for clots to develop undisturbed)
Increased clotting (high INR), which could be either acquired or inherited.
Some "acquired" risks for clotting disorder.
Surgery,Trauma, Cancer, Travel/prolonged, Bed Rest, Obesity, Hormonal Replacement, Smoking, Central Venous Catheters, Heart Failure, Age 1% per year, Previous DVT.
Some inherited risks for clotting disorder.
Antithrombin deficiency, Protein S or C deficiency, Factor V Leiden, Non O blood group, Hyperhomocysteinemia, High levels of factor VIII, IX, XI.
What is the risk of developing a subsequent DVT after the first?
3-10% per year thereafter.
What evidence indicates that DVT is a result of systemic changes rather than local damage.
Up to half the recurrences occur in the opposite leg.
What are the two clear risk factors for recurrence of a DVT?
Male gender (3-4X risk of reoccurrence)
Absence of a clear precipitating factor for the first event (2X risk of reoccurrence)
In a patient with a Hx of DVT, what is one of the best things you can do to reduce the chance of recurrence.
Examine your treatment to ensure you don't add additional risk factors.
What happens to Pulmonary Artery Pressure after a PE?
It increases as the right side of the heart tries to pump blood into it without being able to escape.
Which heart chambers are connected to the pulmonary arteries?
What happens to the right ventricle during a large pulmonary embolism?
It becomes strained and distended.
What indications would you see on EKG in a pulmonary embolism
PE=S1, Q3, T3
Lead 1 has a prominent S wave
Lead 3 has a prominent Q wave (always abnormal)
Lead 3 also has an inverted T wave.