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