Pathophys
What is/are the main locations the thrombus in a Pulmonary Embolism likely to arises?
Femoral vein or deep leg veins (popliteal vein is also common)
Why is pregnancy a risk factor for developing a PE?
Women are in a hyper coagulable state in pregnancy
What is the first line treatment for an acute thrombosis of any kind?
Anticoagulants
Bonus:
Give 3 examples and how they work
What can be used to reverse each one?
This is the word used to describe infarcted lung tissue that has become necrotic and leads to capillaries leaking into the alveolar space.
What is Hemoptysis?
A patient with a massive PE may develop hypotension, JVD, and ECG findings showing an S1Q3T3 pattern, due to failure of this heart chamber.
What is the right ventricle?
What constitutes Virchow's Triad?
Endothelial injury
Hypercoagulability
Venous stasis
In an massive acute PE, what therapy is especially indicated and why?
Thrombolytics
Bonus:
If thrombolytics can't be used, then what other procedure may be indicated?
What are some long term symptoms of an massive PE like the one in our patient?
Hemoptysis in pulmonary embolism occurs due to ischemic necrosis of lung tissue, when these two blood supplies fail to compensate for each other
What are the pulmonary artery and bronchial artery?
How does the patient's skin present with a PE and what type of shock is this indicative of?
Cold and clammy
Obstructive shock
To prevent further thrombosis in a patient who is at risk of a venous thromboembolism, what medication is often added?
DOACs - Direct Oral Anticoagulants
Bonus:
Name a second line medication that can also be given for long term therapy anticoagulation
Name a procedure that can be done to prevent future PE
What serum values would we expect to see as abnormal in a PE?
WBCs, BUN/Creatinine ratio
Bonus:
Explain why
What lab value is often used to rule in/rule out an acute PE?
In massive PE, this increased hemodynamic parameter leads to right ventricular dilation, septal bowing, and decreased left ventricular filling, ultimately causing obstructive shock. This other factor is looked at to differ from Cardiac tamponade.
What is pulmonary vascular resistance (PVR)? AND What is PCWP
What heart sounds are expected in a patient with a PE?
Loud P2 component of S2: Due to pulmonary hypertension with a PE, there is expected to be an abnormal P2 (pulmonic valve closing) which is louder.
What study can be ordered to test for a potential PE?
Ultrasound
Bonus:
Explain why and how?
A 30-year-old man is brought to the emergency department after a motor vehicle accident. He has multiple long bone fractures and is confused. Over the next 24 hours, he develops tachypnea, hypoxia, and petechial rash.
Which of the following is the most likely cause of his symptoms?
A) Air embolism
B) Amniotic fluid embolism
C) Fat embolism
D) Thromboembolic PE
E) Septic embolism
Answer: C) Fat embolism
This underlying problem of PE results in low O2 which results in an increase in this compensatory mechanism that ultimately presents as a decrease in this final molecule.
What is V/Q mismatch, increased RR, and decreased CO2?
What is hypercoagulability, and how does it lead to DVT formation?
Hypercoagulability can lead to Deep Vein Thrombosis (DVT) formation because the abnormal clotting makes it easier for blood clots (thrombi) to form in the veins, especially in the lower extremities. These clots can obstruct blood flow and cause damage to the vein walls, which can increase the risk of DVT.
Systemic approach to reading an EKG
Rate/Rhythm
P-Wave Morphology and PR Interval
QRS Complex
ST Segment Morphology, Depression, and Elevation
T-Wave
QTc Interval and U Wave
A 48-year-old woman presents to the clinic with progressive exertional dyspnea and fatigue over the past six months. She denies recent illness, travel, or surgery but notes intermittent episodes of pleuritic chest pain and mild swelling in her legs that resolved spontaneously. Physical examination reveals an accentuated S2 sound and mild peripheral edema. Chest X-ray is unremarkable, but echocardiography shows right ventricular hypertrophy and increased pulmonary artery pressure. A V/Q scan shows multiple mismatched perfusion defects with normal ventilation.
Which of the following is the most likely diagnosis?
A) Acute thromboembolic pulmonary embolism
B) Pulmonary hypertension
C) Interstitial lung disease
D) Fat embolism syndrome
Answer: B) Pulmonary hypertension
These are the common USMLE Buzzwords for PE.
(Obstructive vs Restrictive / issue with ventilation or perfusion / CXR visualization / EKG pattern)
-Obstructive shock (sudden hypotension, cold/clammy skin)
-V/Q mismatch (ventilation without perfusion)
-Hampton’s Hump on CXR (wedge-shaped infarct)
-S1Q3T3 pattern on EKG (indicative of right heart strain)