Pulmonary Embolism

Acute pulmonary embolism UpToDate treatment:

Well's Score DVT PHeS/I HeC 4

What item in the well's score is not objective?

Is alternative diagnosis more likely than PE? Is PE the most likely explanation for the patient.

Revised Geneva Score

Gestalt unstructured implicit clinical evaluation of the physician

Rule out scores

PERC: pulmonary embolism Rule out score

pulmonary embolism rule out criteria or perk score is a validated decision

that can reliably identify very low risk PE patients

{{c1::stable [anticoagulation (no contra) vs IVC filter (yes contra to anticoagulation)] vs unstable [thrombolytic (no contra) vs surgical/catheter embolectomy (yes contra to thrombolytic)]}}

Modified Wells Criteria

DVT PHeS/I

HeC

D-dimer 4- unlikely 4+ likely

How does the A - a gradient change in patients with pulmonary embolism?

How do the following pressures change with pulmonary embolism?

RA pressure: {{c1::increased}}

Pulmonary artery pressure: {{c1::increased}}

LA wedge pressure: {{c1::decreased}}

- decreased LA pressure (measured as PCWP) suggests an intrinsic pulmonary process → obstructive shock (↓ blood to LA)

- an increased PCWP suggests left-sided heart failure leading to right-sided heart failure

What is the most common source of symptomatic pulmonary embolism?

think about how they're closer to the lungs therefore more likely to embolize; distal veins (e.g. calf veins) are less likely to embolize

S₁Q₃T₃ ECG abnormality = {{c1::pulmonary emboli}}

- Deep S wave in Lead 1
- Q wave and inverted T wave in Lead III
- Indicative of right heart strain

What is the first step in management of pulmonary embolism with the following Wells score?

Wells score >4: {{c1::anticoagulation with heparin (before diagnostic testing)}}
Wells score ≤4: {{c1::diagnostic testing}}

What is the treatment for massive, life-threatening pulmonary embolism?

{{c1::Intra-arterial tPA or thrombectomy}}

Massive PE is defined as PE complicated by hypotension and/or acute right heart strain (eg. JVD, RBBB)
→ hypotension: not enough blood to left heart
→ right heart strain: blocked right heart output

What is the recommended anticoagulation for pulmonary embolism in a patient with severe renal insufficiency (GFR < 30 mL/min/1.73m²)?

LMWH and factor Xa inhibitors are not recommended in renal insufficiency because they are metabolized by the kidney

i.e., if there's a high probability of PE → start heparin before doing CT angio.

What is management of a recurrent DVT in a patient who is on subtherapeutic (INR <2.0) warfarin?

{{c1::Oral direct factor Xa inhibitors (eg, rivaroxaban, apixaban)

As effective as warfarin in the treatment of acute DVT or PE and do not increase the risk of bleeding complications.}}

Xarelto 15mg BID w/ food 21 days then 20mg PO daily w/ food

Eliquis 10mg BId for 7 days then 5mg BID daily

Oral direct factor Xa inhibitors (eg, rivaroxaban, apixaban) are as effective as warfarin in the treatment of acute DVT or PE and do not increase the risk of bleeding complications. These drugs have the advantage of rapid onset of action, no requirement for laboratory (eg, INR) monitoring, and no requirement for overlap therapy with heparin. Therefore, these agents are becoming preferred for the treatment of acute DVT and PE. These drugs are an especially good option in patients who have difficulty with the dietary restrictions or frequent INR monitoring required with warfarin. However, these agents should not be used in patients with severely impaired renal function or in those with DVT or PE secondary to malignancy.

Saddle embolus

A saddle pulmonary embolism is a life-threatening condition characterized by a large blood clot that lodges at the bifurcation of the pulmonary artery, obstructing blood flow to both lungs