541 - Pulmonary Circulation

A 36-year-old woman presents to the emergency department with worsening shortness of breath and pleuritic chest pain. Her symptoms began earlier in the day while she was waiting for her bus to return home. She recently returned from China to the US for a business meeting. She denies any sick contacts and has not had these symptoms in the past. Medical history is unremarkable. She takes an OCP and a daily multivitamin. Her temperature is 98.6°F (37°C), BP 135/82 mmHg, HR 112, RR 24, and SpO2 89% RA. A CT angiogram IS performed and demonstrates a filling defect in the pulmonary vasculature. She is immediately started on supplemental O2 and heparin. What is the likely dx?

pulmonary embolism

3 multiple choice options

Most cases of pulmonary embolism arise from which condition that affects the lower extremities?

DVT

Virchow's triad (pulmonary embolism)

-damage to intima (vascular damage)

-circulatory stasis

-hypercoagulable state

Hypercoagulability (Virchow's triad)

-estrogen therapy

-inflammation

-dehydration

2 multiple choice options

Vascular damage (Virchow's triad)

-physical trauma/strain/injury

-microtrauma to vessel wall

2 multiple choice options

Circulatory stasis (Virchow's triad)

-congenital abnormalities affecting venous anatomy

-low HR and low BP

2 multiple choice options

Classic pulmonary embolism sx triad:

-sudden onset of dyspnea

-pleuritic CP

-cough +/- hemoptysis

2 multiple choice options

PE Rule-Out Criteria (PERC)

IDs pts whose pre-test probability is below test threshold

Age < 50

Pulse < 100

SaO2 > 94%

No unilateral leg swelling

No hemoptysis

No recent trauma/surgery

No prior PE/DVT

No hormone use

Well's prediction rule for PE

Previous PE/DVT: +1.5

HR > 100: +1.5

Recent surgery: +1.5

Clinical sx of DVT: +3

What coag study must be ordered for a pt you suspect has pulmonary embolism?

PT/INR

What is the definitive gold standard imaging to dx pulmonary embolism?

pulmonary angiogram

A V/Q scan on a pt with suspected pulmonary embolism can be expected to be:

mismatched

What EKG findings may be seen in a pt with pulmonary embolism?

Wide, deep S wave in lead I

Isolated Q wave in lead III

Inverted T wave in lead III

(S1Q3T3)

In order for an inferior vena cava filter to be placed, the pt must be:

stable

1 multiple choice option

What meds must be initiated at the first suspicion of DVT or PE?

Full dose LMWH/unfractionated IV heparin

+

warfarin

A pt you have dx with pulmonary embolism is deteriorating and is hemodynamically unstable. You decide to initiate thrombolytic tx. Which 2 thrombolytics should you consider?

reteplase

alteplase

A 48-year-old woman presents to the emergency department with worsening exertional dyspnea over the course of a few weeks. She reports mild chest pain when climbing the stairs or walking a few blocks. She has also noticed some swelling in both of her legs. Medical history is remarkable for sarcoidosis and she denies any alcohol, cigarette, or illicit drug use. Physical examination is notable for a loud P2 heart sound, bilateral lower extremity pitting edema, and JVD. Troponin and BNP are not elevated. ECG demonstrates right axis deviation. She is admitted to the cardiac step down unit where she undergoes a right heart catheterization, which demonstrates a mean pulmonary arterial pressure of 67 mmHg at rest. What is the most likely dx?

pulmonary HTN

3 multiple choice options

What condition is characterized by the increased MAP > 25 mmHg at rest in the absence of lung or L sided heart disease?

pulmonary HTN

What is the diagnostic imaging for pulmonary HTN?

R heart cath