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12.12.18 PE

Origin
  • Likelihood of DVT reaching 
    • <1% below the knee
    • 50% proximal
  • But 70% of confirmed PEs come from the leg

Diagnosis
  • DIAGNOSIS OF EXCLUSION
    • 3 points for no likelier diagnosis
    • CXR should be normal - radiographers will ask!
  • Wells criteria blah blah

Distinguishing from costochondritis
  • Pain is VISCERAL
    • Not localisable
  • Costochondritis pain:
    • Slow onset
    • Specific site
    • Worse on movement

Differentials - do a CXR
  • Pneumonia
  • Pericarditis
  • Pneumothorax
  • Autoimmune pleurisy (cross-reactivity)
    • SLE
    • RA

Investigations
  • CXR
    • Usually completely normal
    • Atelectasis
    • Wedge infarct
    • Haemorrhagic exudative pleural effusion
  • ECG
    • Sinus tachy
    • S1Q3T3
  • ABG
    • Hypoxia
      • Blood shunted down non-alveolar vessels
    • Respiratory alkalosis
  • CTPA
    • Only picks up >5mm clots
      • cf. Multiple small clots; Eventually present with R. heart failure
    • Sometimes a clot can disappear before CTPA is done
  • VQ scan
    • Picks up everything
  • D-dimer
    • Infection
      • Think of DIC, but sub-clinical - Lots of clotting + breakdown!
    • Surgery
    • Cannulas!
    • Renal failure

Management
  • Oxygen => Sats >95%
  • Analgesia to allow deep breathing
  • LMWH
  • Add warfarin once confirmed
    • Or immediately in some trusts to save bed days
    • Don't forget to overlap with heparin
  • Continue anticoagulation for 6 months
  • Concurrent stroke
    • No warfarin/heparin
    • IVC filter

Massive PE
  • Diagnosis
    • Haemodynamic compromise
    • Trop rise
    • Echo evidence of RV strain
  • Management
    • 2222
    • Thrombolysis
    • Embolectomy

Thrombophilia screen
  • Indications 
    • First episode of thrombosis in patient under 50 years of age with no obvious risk factor
    • Atypical thrombosis e.g. subclavian vein 
    • First degree relative with history of thrombosis with no risk factor or thrombophilia
      • Particularly if individual being considered for oral contraceptive or HRT
    • Mid trimester foetal loss or recurrent foetal loss ( 3 or more consecutive) 
    • Recurrent thrombosis 
    • Skin necrosis following use of warfarin 
    • Neonatal thrombosis 
  • Timing 
    • Avoid testing in the acute phase of thrombosis as acute phase changes may be present
      • If related to thrombosis should be 4 weeks after completion of anticoagulation
    • Should not be on Heparain or Warfarin
    • Pregnancy, oral contraceptives, HRT and cancer chemotherapy may also affect some tests
    • Avoid intercurrent severe illness
    • Factor V Leiden and Prothrombin mutation are PCR tests so can be carried out in patients on anticoagulants and in acute phase
      • However, other tests will also be required later to exclude dual pathology
  • Tests performed 
    • Full blood count 
    • PT APTT Fibrinogen 
    • Antithrombin III 
    • Protein C 
    • Protein S 
    • APC resistance 
    • Factor VIIIc 
    • Thrombin Time 
    • Factor V Leiden 
    • Prothrombin mutation 
    • Anticardiolipin antibody 
    • Lupus anticoagulant screen

DVT prophylaxis 
  • Cost-benefit
    • 20p for LMWH
    • £5,000 for PE
  • Contraindications
    • Renal failure
      • But can use if monitored
    • Active bleed
    • Thrombocytopenia

Fetal warfarin syndrome 
  • Also known as DiSala syndrome
  • Associated conditions:
    • Hypoplasia of nasal bridge
    • Laryngomalacia
    • Pectus carinatum
    • Congenital heart defects
    • Ventriculomegaly
    • Agenesis of the corpus callosum
    • Stippled epiphyses
    • Telebrachydactyly
    • Growth retardation
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