Who? How?
The incidence of VTE:
A.) Increases linearly with age
B.) Has a bimodal distribution with highest incidence in the very young and very old
C.) Is 10x higher in 70+ year olds compared to 40 year olds
D.) Is 3x higher in patients aged 70+ compared to patients aged 45-69
E.) Is 10x higher in patients aged 45-69 compared to patients aged 20-44 years old.
Correct answer: D
The incidence of VTE is 3x higher in patients aged 70+ compared with patients aged 45-69.
What examination finding helps initially guide testing modalities for PE?
A. Pain, redness and/or swelling
B. Hemodynamic stability/instability
C. Cough/hemoptysis
D. Unilateral/bilateral limb edema
B. Hemodynamic stability/instability
If the patient is hemodynamically unstable, use bedside echo or venous US.
If the patient is stable, use definitive diagnostic imaging.
The high sensitivity low specificity test for a PE: ___
d-dimer
*age-adjusted d-dimer is standard
When treating a known PE, which of the following are primary goals of treatment? SELECT ALL THAT APPLY
A) Oxygenation
B) Hemodynamic stability
C) Reperfusion of the lung
A) Oxygenation
AND
B) Hemodynamic stability
Reperfusion is a secondary goal of treatment
Patients should typically remain on anticoagulation after PE for how long?
A) 1 month
B) 3 months
C) 6 monhts
D) 1 year
E) Indefinitely
B) 3 months.
The rule is the rule.
PE incidence is [increasing/decreasing] and PE mortality is [increasing/decreasing] in the United States.
PE incidence is increasing; PE mortality is decreasing
In the hemodynamically stable patient with suspected PE, an assessment is conducted to determine PE probability.
What PE probability assessment score would put the patient in a high PE probability category?
A. Between 0-2 points
B. Between 2-4 points
C Between 4-6 points
D. 6+ points
D. 6+ points on a PE probability assessment would place the patient in a high PE probability category.
Gold-standard high specificity test for PE: ____
Chest CT-angiography
A 70 year old female is in the hospital receiving treatment for a traumatic head injury. While in the hospital she develops new shortness of breath. CT-A confirms there is a PE. Which of the following is the most appropriate treatment?
A) Warfarin
B) Enoxaparin
C) Inferior Vena Cava Filter
C) Inferior Vena Cava Filter
Anticoagulation is contraindicated in someone with recent head trauma. An IVC is used when anticoagulation is contraindicated.
Which of the following indicates a worse prognosis in the setting of PE?
A) Elevated troponin
B) Elevated BNP
C) Shock
D) All of the above
D) All of the above.
Elevated troponin indicates cardiomyocyte damage. Elevated BNP is due to increased right heart strain. And patients that experienced shock with PE have been shown to have poorer prognosis.
Name the three components of Virchow's Triad:
A. hyperlipidemia; arterial stasis; endothelial rupture
B. hypercoagulability; hypertension; hyperlipidemia
C. venous stasis; endothelial injury; hypercoagulability
D. arterial injury; venous stasis; hypertension
C: Venous stasis; endothelial injury; hypercoagulability
What clinical exam findings would help differentiate a pulmonary embolism from a deep vein thrombosis?
A. Limb edema
B. Dilated veins
C. Tenderness to palpation
D. Hypotension
E. Red/hot skin
F. Tenderness to palpation
D. Hypotension
Additionally, sinus tachycardia and hypoxemia may also be seen with PE.
This is the diagnostic algorithm for determining pre-test probability of PE: ___
Wells score
A 33 year old pregnant woman is diagnosed with a PE. Which of the following is the best anticoagulation option for outpatient treatment?
A) Warfarin
B) Unfractionated heparin
C) Dabigatran
D) Enoxaparin
D) Enoxaparin does not cross the placenta, is safe for use in pregnancy, and can be taken orally.
Unfractionated heparin is also safe in pregnancy, but increases the risk of heparin indiced thrombocytopenia (B is incorrect). Dabigatran is category C for use in pregnancy (C is incorrect). Warfarin is teratogenic and should be avoided in pregnancy (A is incorrect).
What is the most common early complication after PE?
A) DVT
B) PE
C) Stroke
D) Shock
E) Pneumonia
B) PE
PEs do not cause DVT because there are 2 capillary beds in the way (A is incorrect).
Stroke, shock, and pneumonia are all possible complications of PE. However, recurrent PE is the most common.
The single most common site for deep vein thrombosis?
A. Upper extremity brachial veins
B. Distal lower extremity peroneal veins
C. Distal lower extremity popliteal veins
D. Distal lower extremity anterior/posterior tibial veins
B. Distal, lower extremity peroneal veins are the most common site for DVT.
[Together, the calf veins, which include peroneal + anterior/posterior tibial, account for 83% of documented DVTs].
You assess a patient who scores 1 point on the PE probability assessment. The patient is 45 years old and has no prior surgeries, DVT/PEs, or hospitalizations. He takes no medications and reports no hemoptysis. Physical examination reveals a HR of 84, RR 14, BP 126/82, 98.8F, and Sp02 of 99% on room air. What is your next step?
A. CT pulmonary angiography
B. Venous ultrasound
C. Echocardiography
D. D-dimer
E. No further PE workup required
E. No further PE workup required
If all PE rule out criteria* can be met, and a patient has a PE probability assessment <2 points, no further PE workup is required.
*Patient age <50; HR<100; Sp0> 95%; no hemoptysis; no estrogen use; no prior DVT/PE; no leg swelling; no surgery/trauma requiring hospitalization within prior 4 weeks
You are seeing a 65 year old male in the emergency department with shortness of breath and a Wells score of <2. The next best diagnostic step is to...
A) Immediately begin anticoagulation
B) Order a d-dimer
C) Order a VQ scan
D) Order a CT-A
E) Work-up for non-PE causes of dyspnea
B) Order a d-dimer.
Given the patient's age >50, PE should remain included on the differential diagnosis (E is incorrect). With a low pre-test probability, we should screen for PE with a highly sensitive test such as the d-dimer. A CT-A is not warranted before a positive screening test in someone with a low pre-test probability (D is incorrect). Similarly, a VQ scan is not necessary, and would also not be the testing modality of choice (C is incorrect). Lastly, immediate anticoagulation is only indicated when the pre-test probability of PE is high (A is incorrect).
You are an amazing doctor and just diagnosed a patient with a PE. This patient was hemodynamically stable, was not in respiratory distress, did not need supplemental oxygen, and had no significant comorbidities. You decide to treat them as an outpatient. Which of the following is the best outpatient monotherapy treatment?
A) Warfarin
B) Unfractionated heparin
C) Dabigatran
D) Enoxaparin
D) Enoxaparin. Factor X inhibitors can be taken orally without heparin bridging making them a convenient choice for outpatient PE treatment.
LMWH can be given subcutaneously as an outpatient. However, this is often inconvenient or undesirable for the patient (A is incorrect).
Unfractionated heparin is given IV, so not a good outpatient treatment choice (B is incorrect).
Dabigatran can be taken PO, but as a direct thrombin inhibitor, it reaches therapeutic INR levels slowly and requires heparin bridging (C is incorrect)
Warfarin also requires heparin bridging (A is incorrect).
Which of the following factors does not affect 30-day mortality after PE.
A) Heart Failure
B) Chronic Lung Disease
C) BMI
D) Shock
C) BMI
PESI score is used to classify 30-day mortality risk. Heart failure, chronic lung disease, and all exam components of shock increase 30-day mortality risk.
You are rounding on a 64-year-old patient who is status-post partial hepatectomy for treatment of hepatocellular carcinoma, with a post-operative course complicated by sepsis. The patient's current vitals are temperature 98.6F, BP 124/78, Pulse 78, Sp02 97%, BMI 33, RR 16.
How many acquired risk factors for PE can you identify?
A. 4
B. 5
C. 6
D. 7
B.
Age, malignancy, surgery, sepsis, and obesity are al acquired risk factors for PE.
A patient undergoes PE probability assessment and is determined to have symptoms of DVT (leg pain and swelling), tachycardia, obesity, and hemoptysis.
What is the patient's PE probability score?
A. 7.5; high probability
B. 6.5; high probability
C. 5.5; moderate probability
D. 3.0; moderate probability
E. 1.5; low probability
C. 5.5; moderate probability
Using PE probability testing metrics:
+DVT symptoms: 3.0 points
+tachycardia: 1.5 points
+hemoptysis: 1 point
= 5.5 points
Moderate risk = between 2-6 points
(Obesity is not a scored metric)
A 55 year old female with history of peripheral vascular disease presents to the emergency department with shortness of breath for 4 days after recent travel. On exam, her blood pressure is 70/40 and her right lower extremity is erythematous.
What is the most appropriate test to evaluate this patient for PE?
A) d-dimer
B) CT-A
C) VQ scan
C) VQ scan
D-dimer is used to screen for PE in patients with a relatively low pre-test probability. This patient's pre-test probability is high (A is incorrect). CT-A is typically the gold-standard testing modality, however it is contraindicated in hemodynamic instability (B is incorrect). A VQ scan is the appropriate diagnostic test for PE in patients with hemodynamic instability.
A 55 year old male patient comes in to the ED with a presumed PE and blood pressure of 70/40. Which of the following medications is the best choice for stabilizing this patient?
A) Norepinephrine
B) Epinephrine
C) Racemic Epinephrine
D) Dobutamine
A) Norepinephrine.
Norephinephrine is more selective for alpha receptors on blood vessels than epinephrine and causes less reflex tachycardia than dobutamine.
Which of the following findings is most likely to be caused by the late complication of PE?
A) Inspiratory crackles on exam
B) Decreased breath sounds on exam
C) Low voltage QRS on EKG
D) Right axis deviation on EKG
D) Right axis deviation
The late complication of PE is chronic thromboembolic pulmonary hypertension (CTEPH). Pulmonary hypertension most frequently causes right ventricular hypertrophy (RVH). On EKG, RVH causes right axis deviation.