PE
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  • What immediate action is recommended for a patient with pulmonary embolism (PE) as a medical emergency?

    Call a met call and arrange ICU admission

    emergency pe

  • What initial oxygen therapy is recommended for suspected PE?

    15 L of oxygen via a nonโ€‘rebreather mask

    management oxygen

  • What must be confirmed about the patient's status during initial PE management?

    Make sure they are hemodynamically stable

    management hemodynamics

  • Which imaging test is listed for investigating suspected PE?

    CTPA

    investigations imaging

  • Which blood test is specifically mentioned for PE evaluation?

    D-dimer

    investigations labs

  • Name three blood investigations (besides D-dimer) listed for PE workup.

    • FBC
    • EUC
    • LFT
    investigations labs

  • Which cardiac biomarkers and related tests are listed for PE evaluation?

    • BNP
    • Troponins
    • Coagulation studies
    investigations cardiac

  • Which ECG findings are mentioned as associated with PE?

    Tachycardia and S1Q3T3

    investigations ecg

  • What key history points should be asked about possible DVT when assessing for PE?

    • Signs of DVT
    • Calf tenderness
    • Asymmetrical swelling
    history dvt

  • Which recent activities or exposures should be asked about in PE history?

    • Recent mobilization
    • Recent long haul travel
    • Use of blood thinners
    history risk

  • Which past medical and medication history items are important for PE assessment?

    • Cancer history and treatments
    • Previous thromboembolic events
    • Coagulopathies
    history pastmedical

  • What aspects of symptoms should be asked about for suspected PE?

    • Chest pain and if it is pleuritic
    • Haemoptysis
    • How the patient feels
    history symptoms

  • What examination components are listed for a patient with suspected PE?

    Head-to-toe exam including lung and heart auscultation, carotids, renal bruits, calf tenderness, vitals, peripheral vascular, neurological

    examination pe

  • When should you perform a CTPA based on the Wells score?

    If Wells score is more than 4

    wells imaging

  • What is the recommended pathway if the Wells score is below 4?

    Do a D-dimer and other investigations; if D-dimer is high or cause not found, do CTPA and consult ED/ICU

    wells pathway

  • What CXR signs may indicate pulmonary embolism?

    • Knuckle sign
    • Palla sign
    • Hampton hump
    • Westermark sign
    • Fleischner sign
    • Chang sign
    • Polo mint sign
    • Railway sign
    • Pleural effusion
    • Saddle embolism
    radiology pulmonaryembolism cxr

  • What pregnancy-related tests or questions should be asked in a woman with suspected PE?

    Ask about contraceptives and pregnancy and perform a bHCG

    history pregnancy pe

  • When is a patient with PE considered haemodynamically unstable?

    If systolic blood pressure is <90 mmHg or drops >40 mmHg from baseline

    definitions hemodynamics pe

  • What is the recommended alteplase regimen for thrombolysis in PE for patients >65 kg?

    10 mg IV bolus followed by 90 mg infusion over 2 hours

    thrombolysis alteplase pe

  • What is the recommended alteplase regimen for thrombolysis in PE for patients <65 kg?

    10 mg IV bolus followed by 1.5 mg/kg infusion over 2 hours

    thrombolysis alteplase pe

  • What are typical maintenance anticoagulation options after initial PE treatment?

    LMWH (enoxaparin, dalteparin) or oral anticoagulants (NOACs such as apixaban or rivaroxaban); warfarin or dabigatran as alternatives

    anticoagulation pe treatment

  • What do the 2021 American guidelines suggest about NOACs for cancer-associated VTE?

    NOACs can be used for cancer-associated VTE

    guidelines cancer noacs

  • When should an IVC filter be considered in PE management?

    If anticoagulation is contraindicated or there is failure of appropriate anticoagulation/recurrent PE

    intervention ivcfilter pe

  • Which anticoagulants are contraindicated in pregnancy for PE?

    Warfarin (teratogenic) and DOACs such as dabigatran (likely cross placenta) are contraindicated

    pregnancy anticoagulation pe

  • Which anticoagulant is used in massive PE with haemodynamic compromise or when rapid adjustment/reversal is needed in pregnancy?

    Unfractionated heparin

    pregnancy heparin pe

  • What is the recommended management of enoxaparin in pregnancy and postnatally for PE?

    Continue enoxaparin for the remainder of pregnancy and at least 6 weeks postnatally for a total of 3 months; postnatally you can switch to a DOAC

    pregnancy enoxaparin pe

  • What is the typical duration of anticoagulant therapy after a PE when no ongoing risks exist?

    Typically stopped at 3 months unless factors predicting recurrence are present

    duration anticoagulation pe

  • Which alternative anticoagulant can be used when heparin is not tolerated (e.g., HIT)?

    Fondaparinux

    alternatives fondaparinux pe

  • What is the immediate priority in suspected acute pulmonary embolism?

    • Emergency recognition and initial resuscitation
    pulmonaryembolism emergency

  • Which clinical pathway components are used for diagnosing pulmonary embolism?

    • Wells score, D-dimer, CTPA pathway
    pulmonaryembolism diagnosis

  • What defines the subgroup of pulmonary embolism patients who may need thrombolysis?

    • Hemodynamic instability indicates consideration of thrombolysis
    pulmonaryembolism thrombolysis

  • What are the two core aspects of medical management after acute PE stabilization?

    • Anticoagulation options and duration of therapy
    pulmonaryembolism anticoagulation

  • What special patient group requires tailored PE management considerations?

    • Pregnancy and special situations
    pulmonaryembolism pregnancy
ํ•™์Šต ๋…ธํŠธ

Pulmonary Embolism (PE) โ€” Quick Study Notes

Overview

  • PE is a medical emergency; activate a MET call and consider ICU for unstable patients.
  • Immediate goals: secure oxygenation, assess hemodynamics, and start appropriate anticoagulation or thrombolysis.

Key definitions

  • Hemodynamically unstable PE: systolic blood pressure \(\text{SBP} < 90\ \text{mmHg}\) or a drop of \(>40\ \text{mmHg}\) from baseline.
  • Wells score used for pre-test probability to guide imaging and D-dimer use.

Initial emergency management (first minutes)

  • Give high-flow oxygen: \(15\ \text{L/min}\) via non-rebreather mask.
  • Call MET/critical care and prepare for possible ICU transfer.
  • Monitor vitals continuously, establish IV access, and obtain urgent investigations.

History โ€” important points to ask

  • Recent immobility or long-haul travel; recent surgery or trauma.
  • Symptoms: pleuritic chest pain, dyspnea, hemoptysis, syncope.
  • Signs or history of DVT: calf pain, unilateral swelling, prior VTE.
  • Anticoagulant use, contraceptives, pregnancy (bHCG), active cancer, thrombophilia.
  • Renal disease (affects DOAC use and contrast for CTPA).
  • Comorbidities: diabetes, hypertension, bleeding history, alcohol and smoking.

Examination โ€” focused elements

  • Full head-to-toe exam but emphasise:
  • Respiratory: breath sounds, pleural rubs, effusion signs.
  • Cardiovascular: tachycardia, raised JVP, new murmur.
  • Limbs: calf tenderness, unilateral swelling, Homan's sign (limited value).
  • Neurological and perfusion: syncope, hypotension, cool peripheries.

Investigations

  • Immediate:
  • ECG โ€” look for sinus tachycardia and S1Q3T3 pattern.
  • Bloods: FBC, EUC (renal function), LFTs, CRP, coagulation studies, troponin, BNP.
  • D-dimer (when pre-test probability is low or moderate).
  • ABG if respiratory compromise.
  • Blood cultures if sepsis suspected.
  • Imaging:
  • CTPA is the diagnostic test of choice when indicated.
  • Chest X-ray helpful to exclude other causes and show PE signs (see image).

Chest X-ray signs of PE

  • Classic but uncommon radiographic signs: Knuckle sign, Palla sign, Hampton hump, Westermark sign, Fleischner sign, Polo-mint, Railway sign, pleural effusion, saddle embolus.

Pulmonary embolism chest X-ray signs

Alt text: Diagram of chest X-ray signs of pulmonary embolism.

When to do CTPA

  • If Wells score > 4 โ†’ proceed to CTPA.
  • If Wells score โ‰ค 4 โ†’ get D-dimer; if D-dimer elevated or suspicion persists, then do CTPA.

Hemodynamic risk stratification

  • Unstable (massive PE): shock, hypotension (\(\text{SBP} < 90\)) or large drop in BP.
  • Stable (submassive or low risk): normotensive but may have RV strain or elevated biomarkers.

Definitive management

  • General: start anticoagulation unless contraindicated.
  • If haemodynamically unstable (massive PE): consider systemic thrombolysis (alteplase):
  • For patients >65 kg: \(10\ \text{mg}\) IV bolus + \(90\ \text{mg}\) infusion over \(2\ \text{h}\).
  • For patients <65 kg: \(10\ \text{mg}\) IV bolus + \(1.5\ \text{mg/kg}\) infusion over \(2\ \text{h}\).
  • Give in monitored setting (ICU) and prepare for bleeding management.
  • If thrombolysis contraindicated or fails: consider surgical or catheter-directed embolectomy.

Anticoagulation (maintenance)

  • First-line for most stable patients: NOACs/DOACs (e.g., apixaban, rivaroxaban).
  • Alternatives: LMWH (enoxaparin, dalteparin) or warfarin if DOACs unsuitable.
  • Cancer-associated VTE: guidelines now support DOACs as an option; consider bleeding risk and drug interactions.
  • Typical planned duration: at least \(3\) months; extend if ongoing risk (active cancer, recurrent VTE, thrombophilia).
  • Use an IVC filter only when anticoagulation is contraindicated or recurrent PE despite adequate therapy.

Pregnancy and peripartum

  • Avoid warfarin (teratogenic) and most DOACs (placental crossing uncertain).
  • Use LMWH (enoxaparin) throughout pregnancy; continue at least \(6\) weeks postnatally for a total of \(3\) months.
  • Unfractionated heparin may be preferred in massive PE or when rapid reversal is needed around delivery.
  • Consider fondaparinux if heparin intolerance (e.g., HIT) and expert input.

Special considerations

  • Renal impairment: adjust or avoid certain DOACs and contrast for CTPA; check renal function before DOACs.
  • Bleeding risk: balance anticoagulation vs. thrombolysis; involve haematology when complex.
  • Ongoing monitoring: observe for RV dysfunction (echo), rising troponin or BNP indicating higher risk.

Practical algorithm (brief)

  1. Airway/oxygen: \(15\ \text{L/min}\) NRB; call MET/ICU.
  2. Assess vitals and compute Wells score.
  3. If Wells \(>4\) โ†’ CTPA. If Wells \(\le 4\) โ†’ D-dimer, then CTPA if elevated.
  4. If unstable โ†’ thrombolyse (follow dosing) and ICU care.
  5. Start anticoagulation in all without contraindication; decide long-term agent and duration.

Key takeaways

  • Treat PE as an emergency; stabilise airway/oxygenation and circulation first.
  • Use Wells + D-dimer to decide imaging; CTPA is diagnostic standard.
  • Hemodynamically unstable patients may need thrombolysis or embolectomy.
  • Most stable patients receive DOACs or LMWH, typically for at least \(3\) months.