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OSCE 463: Pulmonary Embolism

Introduction

A 69-year-old man with a 2-month history of weight loss, jaundice and abdominal distension presents feeling acutely unwell. His SpO2 is 87% on air…

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Case Information

This ECG has been done 30 minutes ago…

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Question No. 3

Q: What does the ECG show? (2 marks)

Answer No. 3

  • Incomplete RBBB 1 (rSR’ in V1)
  • T wave inversion in V1-V3 1 (mimics anterior ischemia)
  • Sinus tachycardia 1

2

Question No. 4

Q: Given the history and ECG findings, give a differential diagnosis? (2 marks)

Answer No. 4

  • Pulmonary embolism (PE) 1
  • Acute coronary syndrome 1
  • Pulmonary oedema 1
  • Pneumonia 1
  • Pneumothorax 1
  • Pleural effusion 1

2

Case Information

You suspect a diagnosis of pulmonary embolism (PE)…

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Question No. 6

Q: Suggest some suitable, immediate bedside investigations? (2 marks)

Answer No. 6

To Determine Diagnosis
  • Clinical scoring +/- D-dimer: 0.5
    • Well's score
  • Imaging (stable patient)
    • CTPA - 1st line
    • V/Q scan - if normal chest x-ray
    • Pulmonary angiography (if diagnosis remains uncertain)
  • Imaging (unstable patient)
    • Transthoracic echocardiography (TTE)
  • Chest x-ray 0.5(to exclude other pathology)
To Determine Severity / Prognosis
  • Transthoracic echocardiography 0.5
  • Troponin 0.5
  • BNP 0.5
  • Arterial blood gas 0.5
  • ECG 0.5
  • PESI score
To Assess for Complications
  • Screen for malignancy
  • Thrombophilia screen

2

Question No. 7

Q: Name 2 scoring systems applicable to PE? (2 marks)

Answer No. 7

  • To determine diagnosis
    • Well's score 1:
      • 3-level: low, moderate or high risk
      • 2-level: likely or unlikely (Recommended by NICE)
    • Geneva score 1
    • Pulmonary Embolism Rule-out Criteria (PERC) 1:
      • Used for ruling out PE in low-probability cases
  • To assess severity & prognosis
    • Pulmonary Embolism Severity Index (PESI) 1

2

Question No. 8

Q: In the absence of haemodynamic instability name 2 features that would make this a suspected intermediate-risk PE? (2 marks)

Answer No. 8

  • Absence of haemodynamic instability with PESI Class III-IV 1 and one of the following:
    • RV dysfunction on imaging1
    • Rasied troponin1
    • Raised BNP1
    Early Mortality Risk
    Early Mortality Risk
    Risk Parameters & Scores
    Risk Parameters & Scores
    Risk Parameters & Scores
    Risk Parameters & Scores
    Early Mortality Risk
    Early Mortality Risk
    Haemodynamic Instability
    PESI class III-V
    Signs or RV Dysfunction on Imaging
    Cardiac Laboratory Biomarkers
    High
    High
    +
    (+)
    +
    (+)
    Intermediate
    High
    -
    +
    Both positive
    Both positive
    Intermediate
    Low
    -
    +
    Either one (or none) positive
    Either one (or none) positive
    Low
    Low
    -
    -
    -
    Assessment optional but negative if assessed
    ESC Guidelines

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    2

    Question No. 9

    Q: Other than impaired right ventricular function what abnormal features on a transthoracic echocardiogram would support a diagnosis of PE? (3 marks)

    Answer No. 9

    • Dilatation of the right ventricle 1
    • Impaired right ventricular function
    • Flattened intraventricular septum 1
    • Distended inferior vena cava with diminished inspiratory collapsibility 1
    • Tricuspid regurgitation 1
    • Mobile thrombus in the right heart 1

    Dilatation of the right ventricle

    • Basal RV/LV > 1.0 
    • RV >4cm at the base in the 40 chamber view

    Impaired right ventricular function

    • Tricuspid annular plane systolic excursion (TAPSE) <16 mm
    • May be evident on visual evaluation

    McConnel's sign

    • Normokinesia and/or hypokinesia of the apical segment of the RV free wall despite hypokinesia and/or akinesia of the remaining parts of the RV free wall

    Flattened intraventricular septum

    Distended inferior vena cava with diminished inspiratory collapsibility

    Tricuspid regurgitation

    • Velocity greater than 2.7 m/sec by colour doppler flow imaging

    Mobile thrombus in the right heart

    ESC Guidelines

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    3

    Question No. 10

    Q: What are the indications for thrombolysis in PE? (1 marks)

    Answer No. 10

    • High-risk (massive) PE 1
    • Selected cases of intermediate-risk (sub-massive) PE:
      • Currently not routinely recommended by ESC guidance
      • Some evidence it improves long term outcomes
    ESC Guidelines

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    1

    Question No. 11

    Q: Name 4 contraindications to thrombolysis in pulmonary embolism? (2 marks)

    Answer No. 11

    Absolute
    • History of intracranial hemorrhage, intracranial neoplasm, arteriovenous malformation, or aneurysm 0.5
    • Recent (<2 months) intracranial surgery or trauma 0.5
    • Active or recent internal bleeding 0.5
    Relative
    • Known bleeding diathesis 0.5
    • Non-haemorrhagic stroke within the prior 2 months 0.5
    • Surgery within the previous 10 days0.5
    • Thrombocytopaenia (platelets <100x109/l 0.5
    • Uncontrolled severe hypertension (systolic BP >200mmHg or diastolic >110mmHg) 0.5

    2

    Question No. 12

    Q: Give 2 options recommended for initial anticoagulation in pulmonary embolism? (2 marks)

    Answer No. 12

    Acute Management
    Parenteral, weight-adjusted anticoagulation should be used:
    • Low-molecular weight heparin (LMWH) SC 1
    • Fondaparinux SC 1
    • Unfractionated heparin (UFH) IV 1
      • Generally second line due to higher bleeding risk and HIT risk
      • Preferred agent in the setting of:
        • Overt haemodynamic instability or imminent haemodynamic decompensation in whom primary reperfusion treatment will be necessary (short half life and easy reversal)
        • Increased risk of bleeding
        • Serious renal impairment (creatinine clearance <30 mL/min)
    Longer-Term Management
    Started when the patient's condition is stable and no invasive procedures are planned
    • Non-vitamin K oral anticoagulant (NOAC)
    • Warfarin international normalized ratio (INR) is 2.0 to 3.0:
    ESC Guidelines

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    2

    Question No. 13

    Q: What other investigations should be considered in the case of this patient? (2 marks)

    Answer No. 13

    To determine the underlying cause:
    • Suitable investigations for likely underlying malignancy 1 (as suggested in the opening question)
    • Thrombophilia screen 1

    2

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