Introduction Defined as occlusion of a pulmonary artery from embolization of a thrombus from a distal site size of embolism determines proximity of occlusion to pulmonary trunk Saddle embolus large clot that occludes central pulmonary arteries most commonly due to a thromboembolism from the deep veins of the leg highest number originate from femoral vein Risk factors Virchow's triad stasis immobility CHF obesity surgery hypercoagulability pregnancy OCP protein C/S deficiency factor V Leiden severe burns cancer endothelial damage exposed collagen stimulates clotting cascade trauma fracture previous DVT Presentation Dyspnea and tachycardia common presenting findings May see hypoxemia on pulse oximetry and ABG ABG often shows ↓ PO2, ↓ PCO2, ↑ A-a gradient Pleuritic chest pain Sudden death acute right heart failure from rapid increase in pulmonary artery pressure more common with saddle embolism Pleural friction rub Fever if pulmonary infarct Deep vein thrombosis Homans' sign dorsiflexion of foot leads to tender calf muscle not present in the majority of cases (not sensitive or specific) erythematous, swollen, warm, lower extremity Imaging Chest CT with angiography test of choice in most circumstances visualize filling defect in pulmonary artery V/Q radionuclide scan ↓ pulmonary perfusion without decreased ventilation to given area used when patient cannot tolerate CT contrast (renal failure, pregnancy) requires a normal chest xray to be useful pulmonary angiogram gold-standard confirmatory test rarely used Studies Labs serum D-dimers result of clot degradation only useful if low pretest probability (Wells criteria) high sensitivity but low specificity Treatment Pharmacologic anticoagulation heparin or low-molecular weight heparin (LMWH) warfarin begin for long term anticoagulation thrombolysis in cases of hemodynamic compromise Operative inferior vena cava filter indicatied if anticoagulation is contraindicated or if patient develops a PE while on anticoagulants thrombectomy in cases of hemodynamic compromise and contraindication to thrombolytic therapy Prevention Subcutaneous heparin or LMWH most effective for immobile patients or patients at high risk early ambulation as able Sequential compression devices when pharmacologic prophylaxis is contraindicated Complications Pulmonary infarction most cases do not result in infarction due to large degree of collateral circulation in the lungs occur when patient has a reduction in pulmonary blood flow secondary to decreased cardiac output or obstructive lung disease Death Due to right ventricular failure
QUESTIONS 1 of 5 1 2 3 4 5 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M1.PL.20) A 73-year-old female is hospitalized following a pelvic fracture. She undergoes surgical repair without complication. Four days into her hospital stay, she develops acute dyspnea and chest pain accompanied by oxyhemoglobin desaturation. Which of the following arterial blood gas values is the patient most likely to have? (normal values: pH 7.35 - 7.45, PaO2 80 - 100 mm Hg, PaCO2 35-45 mm Hg, HCO3 22-26) Review Topic QID: 100823 1 pH 7.5, PaO2 60, PaCO2 30, HCO3 22 40% (2/5) 2 pH 7.3, PaO2 60, PaCO2 30, HCO3 20 0% (0/5) 3 pH 7.5, PaO2 60, PaCO2 50, HCO3 28 40% (2/5) 4 pH 7.3, PaO2 60, PaCO2 50, HCO3 24 20% (1/5) 5 pH 7.4, PaO2 60, PaCO2 40, HCO3 24 0% (0/5) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (M1.PL.4) Four days after undergoing an elective total hip replacement, a 65-year-old woman develops a DVT that embolizes to the lung. Along with tachypnea, tachycardia, and cough, the patient would most likely present with a PaO2 of what? Review Topic QID: 100807 1 120 mmHg 0% (0/3) 2 110 mmHg 0% (0/3) 3 100 mmHg 67% (2/3) 4 85 mmHg 0% (0/3) 5 60 mmHg 33% (1/3) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 5 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK