pulmonary embolism

[arthrodisiac]

Someone explain this answer to me like im a dumb 3rd year

a 40 year old retired football player complains of sudden onset of palpitations and shortness of breath 5 days after having knee replacement surgery. his pulse is 100 and regular. o2 sat 90 on ra. ecg shows sinus tach. a chest xray is negative. which of the following is next step in mgmt?

1- abg
2- doppler of le
3- V/Q scan
4- administer o2
5- administer heparin


Now, alot of questions make the excuse...such and such answer isnt correct because it takes time to do. This particular question says that you do an abg. wtf? So, i guess you wont give o2..cuz that takes too friggen long?...you wont do a v/q scan??? doppler is ******ed and no heparin until things are clearer. but abg, what the hell?

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[mohaven]

Someone explain this answer to me like im a dumb 3rd year

a 40 year old retired football player complains of sudden onset of palpitations and shortness of breath 5 days after having knee replacement surgery. his pulse is 100 and regular. o2 sat 90 on ra. ecg shows sinus tach. a chest xray is negative. which of the following is next step in mgmt?

1- abg
2- doppler of le
3- V/Q scan
4- administer o2
5- administer heparin


Now, alot of questions make the excuse...such and such answer isnt correct because it takes time to do. This particular question says that you do an abg. wtf? So, i guess you wont give o2..cuz that takes too friggen long?...you wont do a v/q scan??? doppler is ******ed and no heparin until things are clearer. but abg, what the hell?

This is according to my understanding... An abg will show reduced PCO2 due to tachypnea and a normal PO2, and pH may be high. In this clinical setting (post knee surgery) this can be a very sensitive finding for an experienced doctor and enough to make the diagnosis of pulmonary emoblism. Doppler of leg is a plausible investigation but not in this acute setting as it may not identify anything. V/Q scan is done in some centers that I know in the above setting as it is very sensitive and specific. From what I have read it is not wise to give O2 of PO2 and oxygen saturation are normal as you may reduce respiratory drive further aggravating the dyspnea. Administration of heparin should be done as soon as diagnosis is clinched which must be after V/Q scan...

 

[arthrodisiac]

idk. the guy had an orthopedic procedure. pe is usually 5 days post op, ecg sinus tach, 90 is cutoff for normal, dont see why you would waste time with abg and go straight for vq, not to mention that abg hurts like a bitch and likely wont help the guys breathing.

 

[watermen]

idk. the guy had an orthopedic procedure. pe is usually 5 days post op, ecg sinus tach, 90 is cutoff for normal, dont see why you would waste time with abg and go straight for vq, not to mention that abg hurts like a bitch and likely wont help the guys breathing.

I remember, in my surgery rotation, those that got a O2 sat near or below 90% almost always get an ABG stat...other thing can be considered later...

 

[arthrodisiac]

I understand All im saying is that, at least from my experience, they will do a vq anyway. so whats the point of doing an abg and a vq? theyll probably get d-dimer as well....just seems like an overload of evidence.

 

[watermen]

I understand All im saying is that, at least from my experience, they will do a vq anyway. so whats the point of doing an abg and a vq? theyll probably get d-dimer as well....just seems like an overload of evidence.

On my surgery rotation, no one likes d-dimer...because it is pretty useless.

 

[DrMom]

I understand All im saying is that, at least from my experience, they will do a vq anyway. so whats the point of doing an abg and a vq? theyll probably get d-dimer as well....just seems like an overload of evidence.

don't confuse board questions with real-world practice. they don't always mesh.

 

[arthrodisiac]

An unrelated question, i didnt want to start another topic. Im taking step 2 tomorrow...if i take it now, it is automatically reported, or is there somewhere on the website or at the test center i can say i want it to be secret unless i let it out?

thanks

 

[dmitrinyr]

As other have pointed out board questions and real-practice are often different and so one should not confuse what they've seen on the wards and what the books tell you to do when you see such and such question. How I understand it (and correct me if I'm wrong), any time you are considering PE as the dx based on the pt's presentation, the first thing you do is an ABG. Look at the A-a gradient and the presence of hypoxia and hypocapnea and that can might sway you opinion towards PE. Then you can go ahead and get V/Q scan or Spiral CT of Chest and put pt on O2. On the wards, you never just do one thing. Many things are always done at the same time and so a pt with suspected PE would be getting an ABG, while having O2 delivered by nasal cannula and someone is scheduling a V/Q scan/ Spiral CT upstairs in radiology.

 

[JayneCobb]

I understand All im saying is that, at least from my experience, they will do a vq anyway. so whats the point of doing an abg and a vq? theyll probably get d-dimer as well....just seems like an overload of evidence.

It's hard not to fall back and not answer the gold standard test for these type of questions. But initially the abg is the fastest test you can do, and you will potentially gleam quite a bit of useful information.

And as for the d-dimer, I'd never order one in a case where the probability is moderate to high that it is a pe.

 

[cbdoctor]

I don't mean to throw a wrench in the thread, but. . .

I just did another UW with a different answer (aggravating!)

Old lady, 3rd day post-op, anxious, tachypneic, tachycardic, 84% on 6L O2, CXR clear.

What the next best step in management
1. ABG
2. V/Q
3-5 Other

Answer per UW? --> V/Q!!!!

I put ABG b/c of former UW questions and THIS thread, but alas, I was wrong.

WHHHYYY. UW says ABG would not be helpful BECAUSE the patient is hyperventilating and hypoxic/hypocapneic.

 

[arthrodisiac]

i guess if you know she is hyperventilating then you know that she is going to be alkalotic and hypocapneic...so it wont tell you much else. But now you understand my frustration.

 

[QuinnB]

I think the abg is less diagnostic, given that you never "diagnose" PE with an ABG. It would be important to do first given that the patient's O2 sat is low and you want to get an idea of how severely they hypo/hyperventilating (may guide decision for intubation, etc...).

To be honest, the guy would already be on O2 and at my institution, you'd be luck if you could pull the ABG off before the guy was sent for a Thoracic CT scan. We don't do V/Q scans - people just get pissed off when it comes back intermediate...and might I add that I hate the d-dimer (except in DIC, then it's okay) given that someone else drawing it has backed me into so many corners and wasted so much money ruling out something that was low prob anyway.

 

[JunkintheTrunk]

An unrelated question, i didnt want to start another topic. Im taking step 2 tomorrow...if i take it now, it is automatically reported, or is there somewhere on the website or at the test center i can say i want it to be secret unless i let it out?

thanks

on eras you have the option to have the programs not see the scores until you want them to, or you can have them sent automatically no matter what.

 

[arthrodisiac]

on eras you have the option to have the programs not see the scores until you want them to, or you can have them sent automatically no matter what.

I understand, but I took it before I even started an ERAS account. So im assuming that if I don't have an account it will automatically upload.