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inv of choice for PE - fawkes
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02-07-2007, 01:18 AM
If in a case of pulmonary embolus, if the initial V/Q scan shows low probability for Pulmonary embolus, n EKG shows sinus tachy n CXR shows no abnormalities. then what is the nxt investigation to be done???
1. Pulmonary angiography 2. Echocardiography
02-07-2007, 01:53 AM
id say pul angiography since a low probability scan ud req more tests to rule out an embolus..but u might like to wait for more responses
02-07-2007, 04:32 AM
spiral ct or pul angio
or we could do a doppler of the leg to determine if the pt has a dvt
02-07-2007, 04:54 AM
kaplan says spiral CT shouldnt be used yet n after the V/Q scan the gold std for dx is a pul angio even if it is invasive...
a venogram for DVT is not routinely done for the DIAGNOSIS of PE...it can defi be done later... this is what i seem to follow from the notes
02-07-2007, 05:06 AM
hey pash what i got out of it was...maybe someone could clarify
do a v/q scan: positive start rx, if low probability do a doppler ultrasound of the legs for dvt.. rx for dvt is same as taht for PE... if thats negative too and there is still a high suspicion for PE do a pul angio spiral ct facilities are not avaliable in all hospitals...
02-07-2007, 05:19 AM
Occlusion of the pulmonary vasculature, typically by a blood clot. Pulmonary infarction MC originate from thromboemboli in the deep saphenous veins of the legs ( 90 %).
If 4 out of 5 of the major pulmonary artery openings are occluded by a massive saddle embolus : Sudden death from acute right heart strain ( acute cor pulmonale ) Generalized vasoconstriction from TXA2 released from platelets and hypoxemia Occlude peripheral vessels and cause V/Q abnormalities : Infarction occurs in < 10 % of cases and is associated with preexisting lung disease and /or left heart failure. Periodic showers of small emboli contribute to the development of pulmonary hypertension (PH). Majority occur in the right lung and in the lower rather than upper lobes. Stasis; Immobility (CHF, AMI), Obesity, Surgery Hypercoagulable state : pregnancy/postpartum, malignancy, hereditary factor deficiencies (AT-III, protein C and S deficiency ), oral contraceptives severe burns] Endothelial injury : Trauma of the pelvis or lower extremity, Post surgical patient (MC) , Recent fracture, Previous DVT ) œSHE Sudden-onset dyspnea follow by pleuritic chest pain are the most common symptoms, while. Cough, Hemopthysis Low-grade Fever Physical =PE : Tachypnea (> 20 /min ) followed by crackles are the most common signs. Cough, Hemoptysis, Hypotension and syncope Sinus tachycardia, Accentuated P2 (PH ) Prominent jugular a wave with right heart failure are also seen, wheezing ( bronchoconstriction from release of platelet factors ), Edematous, tender warm lower extremity; Positive Homans™ sign( calf pain on forced dorsiflexion ) Evaluation: ABGs Hypoxemia (PaO2 < 80 mm Hg ) in 90 % Prolong A-a gradient in all cases Respiratory alkalosis (Pa CO2 < 33 mm Hg) Right ventricular strain pattern (S1Q3, T wave inversion in leads V1-3 )-ECG (50%) Atrial flatters RBBB Wedge shaped density based on the pleura pointing towards the hilum ( Hampton™s sign) Hypovascularity and atelectasis ( Westmark™s sign ) distal to occlusion Pleural effusion ( exudate with neutrophils and increased RBCs ) DIAGNOSTIC TEST V/Q + heparin Angiogram IVC filter if she bleed D-dimmer ( fibrin split products ) V/Q SCAN Considered first step in diagnosing a PE An abnormal V/Q scan (high sensitivity but poor specificity because of preexisting lung disease in some patients ) High probability if there is a lobar defect with ventilation mismatch A œ low probability œ V/Q scan does not exclude a PE, since pulmonary angiography reveals embolization in 15-30 % of cases. PULMONARY ANGIOGRAPHY Gold standard test Survival is closely correlated with making the diagnosis and initiating treatment, 30 % mortality, if undiagnosed For DVT : Doppler is a screening test Venogram is a confirmation test. Treatment Anticoagulation is standard therapy Fibrinollytic therapy sometimes used ( only in solid emboli ) Surgical interruption of the IVC indicated with recurrent embolization So for the PURPOS EOF STEP 2 I WILL GO V/Q FIST , THEN PULMONARY ANGIOGRAM DOPLLER IS SCREENING FOR DVT and VENOGRAM is confirmation na dDVT can predispose to Pulmonary Embolus, Spoiral CT do in the HOSPITALS if yhey will have it, Wea re talking here about STANDAR CARE and protocols, So my final asnwer is ANGIOGRAM !!!!!!!!!!!!!! any dispute welcome..
02-07-2007, 05:28 AM
yeah cd you're right..
first V/Q scan then either Pul angio or doppler of the legs (some prefer to do this before the angio) and it makes more sense to do it before as well just so in case there is a DVT you spare the pt an invasive procedure... thanks for the correction! 
02-07-2007, 05:54 AM
Yes I totally agree with CD45.....The order of preference for the PE investigations shud be:
(1) V/Q scan (2) Doppler U/S of Legs (3) Pulmonary Angiography Thats what I understood from the lectures and from the notes. |
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