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