DIP Episode 339 - The HY Pulmonary Embolism Podcast

Okay, welcome. This is episode 309 of the Divine Intervention Podcasts. In this podcast, I'm going to be talking about Pomonarium Balli and the USMLA exams. We know P Es are a very high-altopic and they are just certain classic things that they love to test on these exams. So first things first, what's a Pomonarium Balli? Well, we know Pomonarium Balli is something that happens and you have occlusion of a Pomonarium artery. Anytime that occlusion of the Pomonarium artery happens in a person that has had a DVT. Right, to remember, most times a DVT is when you have a blood clot that forms in your lower extrudic veins. Anytime it's going to be like the iliac veins, again like a deep vein, that's what's called DVT, deep vein, osterombosis. You have a clot or a thrombus that forms in a deep vein of the leg and then it travels all the way through your inferior vein achiva. And then it's mixed with to your Pomonarium arteries. And obviously when your Pomonarium arteries are obstructed, that becomes a problem. Because your right heart cannot drain properly. The presence right heart will ultimately begin to fail. In fact, there are some Pomonarium physiological consequences to a Pomonarium Balli. So what are those things? The first thing is we know that as your Pomonarium arteries are obstructed, then the presence right ventricle cannot drain properly. And if your right ventricle cannot drain properly, you'll start having some element of shock.

Again, depending on how big the Pomonarium Balli is. And also if you think about it, because your Pomonarium is obstructed, yes, there is adequate ventilation for the lungs, but there is not adequate perfusion. So you have a VQ Mage. In that case, you're EE Gridient or Rice, because again, if you think about it, oxygen is able to get to the LV Lage just fine, right? So your PBG AO2 is okay. But, perfusion cannot come to a Pomonarium coupler very well because of that obstruction, right? So ventilation is okay. Profusion is not there. So because perfusion is not there, your VQ Mage. So your blood is not getting to your lungs to get oxygen either, basically, even if the oxygen is there. So your PBG AO2 is fine for the most part, but your P little AO2 goes lower, right? So that's why your EE Gridient expands. And if you also think about this, these people, because they become hypoxic, their body starts saying, whoo, whoo, whoo, they start trying to breathe and breathe really hard. If you're breathing really hard, you're going to start hyperventilating. You're going to be blowing off a lot of P, you're going to be blowing off a lot of CO2, right? So those people, they develop a respiratory alkalosis, right? So because as your blowing off CO2, your CO2 goes down, right? You're blowing off that CO2, your CO2 goes down. Since your CO2 is down, you're going to develop a respiratory alkalosis, right? So that's something that's very high yield, high yield to no. Right?

So now, what are the risk factors for a pulmonary embolus? On an in-beaming example, the key thing I want to remember is vercolstriode, right? And vercolstriode of hyperquagulability, right? So there's steases. Many people remember it with the term she, right? Right? SHE. So the S stands for steases. The H stands for hyperquagulability, right? And then the E stands for endothelial dysfunction, right? So steases can arise from any different reasons, right? For example, if a person is bedbound, right? When a person is bedbound, then they have blood steases. That's why many times in hospitals, they put these things on your legs to just keep the blood and your lower extremities are contracting. And that's why they like after surgery. They like you to ambolitas quickly as possible. They do all these things to reduce your risk of having a PE. Right? So steases, if you think about it, right? Like for example, a man that is pregnant, right? Again, a man that is pregnant just is not moving around very much, right? All those things can ultimately cause cause problems, right? Or if you think about it, a person that goes on a long plane ride or a long train ride or something like that, right? Again, since you're staining a one place, your blood is not moving as a short, right? And the thing is, I just kind of think of it this way. When you're stoking one place doing nothing, you start doing like strange things, right?

So your blood, when it's just kind of stuck, you kind of start getting in trouble, right? Or like say, for example, a person gets a, a person again, get like, you know, gets drunk and then the, the leon the ground or something for many, many hours. Again, that blood is not really moving anywhere, right? That can cause problems, right? And they hypercogulability, right? There are just many things that can set up a person for hypercogulability, right? So if you have like, for example, factor five lighting, right? With factor five lighting, your factor five is, is almost as like a longer half life than you should, right? So because of that, you're going to have like that person being hypercogulable. If a person has antithrom in three deficiency, right? Because remember normally, antithrom in three, in he beats factors 10 and factor two, right? So people can have that as a genetic disease or they can get an acquired cause of it in the setting of people to have an euphrodix syndrome. Remember one of the proteins you, you pee out in the euphrodix syndrome because your kidney is a leaky, is antithrom in three. So factor two, factor 10, basically those things are no longer being inhibited, right? So you're going to have a high risk of problems, right? And then in the philial dysfunction, right? Again, whenever you have surgery or you have injury or you're in an accident, right? You're pretty much puncture like a blood vessel or something, right?

Again, by doing that, you're pretty much triggering the coagulation cascade, right? So those are all things that can put a person in a pretty bad spot or pretty supposed to get an pulmonary embolite in the first place, right? But again, if they ask you what is the biggest risk factor for a PE, once you pick an azure that says DVT, those people that have a PE, they get it because they had a DVT that arose initially. And remember, there are many other things that can include the pulmonary artery besides just like, you know, like a clot, right? People can have like fat, embolite. Remember, they are going to test that in the context of like a person having like a recent fracture, right? Or like an orthopedic procedure because again, remember the, your bone contains bone marrow. And as you get older, your red marrow shifts towards yellow marrow, right? That yellow marrow is fat, right? So if you have a fracture orthopedic surgical procedure and you have manipulating your bones, that can release some of that yellow marrow. And then that can travel in the bloodstream and look, you know, clota blood vessels, right? And then an air embolite, many times they put it in the context of a pressing getting like a vascular procedure, right? So it can be like, either they got like a central line, please, or something like that, right? And then don't forget, I'm not afraid of embolite.

You'll put a temporal association with the one being like in a third trimester, and maybe having had an abortion or intrauterine fetal demise. And you just see a DIC picture in the setting of a pregnancy. So those are all things, right? That can guide the person towards having a, towards having a, those are all things that kind of essentially include the pulmonary arteries, right? And one thing I just want to say is that these people that have P Es, right? What kind of plural effusion could they have? The thing is usually they will have an exudative plural effusion. Again, many people have this misconception that P Es are associated with transudative effusions. Even when I had that misconception back in the day, it's actually not true, right? So it's very high up to know that P Es only cause exudative effusions, just remember the E in PE for exudative, right? Because the thing is whenever you have a conclusion of a pulmonary artery, there's an inflammatory cascade that gets kick-started, right? And that inflammatory cascade, right? Ultimately leads to the production of many of these inflammatory markers. And those inflammatory markers, one thing they do is they can increase vascular permeability, and that can make your lungs litty, okay? So in general, people that have pulmonary embolite tend to have exudative plural effusions, right? So they're not going to meet with all three of those, basically they're going to violate one or more of our lights, right?

So that's very high up to know. Now, one thing I want to say is how do you know that you're dealing with PE? Well, the big thing is, time frame helps a lot on endemic exams, right? People that have P Es, their condition is acute, right? So it will be highly unlikely for a person to have had a situation for like two to three months, and then you notice that, oh, she all of a sudden is a PE, no, right? A PE is usually going to be an acute event on endemic exams. Although, one thing I would say to watch out for is, let's say a person has had a PE or they've had recurrent P Es, and then you start noticing, you start seeing them having signs and symptoms of like, right, heart dysfunction, like months, years later, right? I want you to think of pulmonary hypertension. Those people have, there's a kind of pulmonary hypertension I believe that's known as CTF, CTEPH, right? Basically, those people would have pulmonary hypertension because they've had like recurrent pulmonary embolite, right? But again, the big thing about PE is the way we'll present on exams, it'll be acute onset, the person will be very short of breath, the person will be hyperventilating, right? Many times, those people are going to be a tacky cardiac, right? Remember, the most common EKG anomaly in a person that has a pulmonary embolite embolose is sinus tacky cardiac, right? I know many people are like, ooh, S1, Q3, T3, to be honest with you, I would not even worry about that for your exam, right?

For the most part, if a person has a PE, they're going to have sinus tacky cardiac, right? The EKG is likely going to be normal, they're just going to be, the heart is just going to be slogging along very quickly, right? The heart is going to be slogging along very quickly. So now, the thing is, when you suspect the PE, what are you supposed to do? So the thing is, there's all these criteria that exist, right? But the thing is, again, the most of these criteria help you answer questions correctly on your exams? No, right? So let me just tell you what you're supposed to do on your exams. The first thing you ask yourself is, is this person low-risk or high-risk? And again, it'll be plenty obvious from the question. So say, for example, if a person is over the age of 35, they smoke, right? And they will know CP's. That person very likely has a PE, that's a high-risk person, right? Now, contrast this with the college athlete that is very active, doesn't use any drugs, has a normal BMI, is not hypoxic or anything like that on labs, right? If you see all those things, that person is low-risk, that's pretty much it, right? The thing is, if you, again, I feel like many people, the thing that kind of crushes them on these USMLA exams, is just pervasive over thinking. You don't have to be an over thinker on these exams. So what I would just encourage you to do is just ask yourself, okay, let me just break things down to the bare bones, bare bones, right?

So breaking things down to the bare bones, are you low-risk or high-risk? If you are low-risk, the first thing I'm supposed to do for those people is to get a D-dimer, right? Get a D-dimer. If the D-dimer is elevated, then you can proceed to a more invasive test, like you can do like a CT and geogram of the chest, that's it, right? But if a person is low probability and you get that D-dimer, and the D-dimer is normal, right? Then you've pretty much crossed out PE, you can go ahead and stop your diagnostic testing at that point. Now, if a person is high-risk, though, like the person I mentioned, you're not going to be messing around with D-dimer, right? You're going to just go straight to the CT and geogram of the chest, right? Those people are very, very high-risk, so in those circumstances, you're just going to go ahead and proceed to CT and geogram of the chest. Now, the thing is, in pregnant women, you have some other considerations. In general, for pregnant women, on in-beaming exams, you really want to try a VQ scan first, right? You try a VQ scan, right? So if VQ scan shows you a high probability for PE, that's all you're done with that, right? That tells you, okay, this pregnant woman likely has a PE. Let's go ahead and start treating her, right? But in a pregnant woman, if you get like any other kind of result from a VQ scan, you need to proceed to a CT and geogram of the chest, right?

Now, one thing I'll go ahead and say is, there are actually certain situations that are not even related to these classic things I mentioned, where you don't do a CT and geogram of the chest, right? So say, for example, a person has like kidney damage, right? A person has like renal dysfunction. That's just like a contraindication to those people getting a CT chest and geogram. But for the most part, I will just say this, if you kind of parse people out as being lures versus high risk, you're pretty much going to be set on end-game exams. And one thing I will say is, sometimes you may see this in error on a test, when you give you a question about a person that is high risk, and they check the D-dimer, and the D-dimer is normal. And then you'll see, what is the next best step? Your next best step, again, is to still get that CT and geogram. Once you're a high risk person for PE, you need to get that CT and geogram, regardless of what the D-dimer shows, okay? Regardless of what the D-dimer shows, that's very important, right? In general, D-dimer should only be administered to people that are low risk, okay? D-dimer should only be administered to people that are low risk. Yes, the D-dimer test is very sensitive, has a very high negative predictive value. But again, it's something you should, on exams, only be administering people that are low risk for PE, right?

Now, one thing I want to go ahead and then say is, what do we usually, like, what's the whole business with a VQ scan? Because that's one thing that people usually confuse. But again, it's actually a pretty simple concept, right? It's a VQ scan, V ventilation, Q, profusion, right? So basically, it's a scan, it's a new clear medicine test, believe it or not, where they will check the ventilation of the lungs and then they will check the profusion of the lungs. And then it's basically like a two-part test, right? They check the ventilation first and then they check the profusion. If you have ventilation, if you notice that, wow! I look at this person as an entire lung and bone. The ventilation graph looks perfectly fine, right? I look at the person's lungs on imaging. The ventilation looks great. Well, then I notice that, wow! The ventilation does it much or perfectly with the profusion in a certain area, right? Then that person likely has some kind of PE. And again, there are many different permutations you have to consider in calling these VQ scans, but that's well beyond the scope of the USM Ls. So we're going to go ahead and skip that, right? Now, one thing I will just see, sometimes in terms of workup, the medication that you give you some questions where, you may notice that doing a CT angiogram is not the right answer or anything like that, but you may not even supply CT angiogram or VQ scan, right? Or even D-dimer as an answer. Let me just see this.

If, for example, they give you a question about like a person that you suspect has a PE. And for some reason, you don't see CT angiogram as an answer, you don't see VQ scan as an answer, you don't see D-dimer as an answer. And they put an answer choice that says to do a duplex ultrasound of the lower extremities. Go ahead and pick that answer. Again, it's just the thing that has the closest relationship to PE in those circumstances. Again, this is just GIMS MANSHAPE for, for exams. But that's one thing, occasionally we see throning on NB exams. And obviously, the gold standard test for diagnosing a PE is a pulmonary angiogram, right? So again, remember, a CT angiogram is not the same thing as a pulmonary angiogram, right? A CT angiogram you inject contrasts into a person's vein, right? And then take pictures of their lungs. A pulmonary angiogram is almost like you're thinking of catheter and dip in contrast in the pulmonary arteries. It's super sensitive, it's super specific, but it's super toxic, right? So, basically you should essentially never perform a pulmonary angiogram on your USMID exams. That's pretty much the way you work up P Es. So now let's talk about what you're supposed to do for P Es, right? For pressing as a PE, what are you supposed to do? Well, you're supposed to treat those people with IV heparin. That's very high up to no. You're supposed to treat those people with IV heparin, IV heparin, right? And the thing is, there are two kinds of heparins in general.

You know, there is low molecular weight heparin and there is unfroxinated heparin. Let me tell you this. The only people that you should really be using on fraction-eat-head heparin are people that have renal dysfunction. For pressing has renal dysfunction, use unfroxinated heparin in those people. Well, for pretty much every other case you see on your exam, use low molecular weight heparin, right? Many times the NBM is not tacky like that, where they would put low molecular weight heparin as an answer or unfroxinated heparin as an answer. If they do both, they're basically trying to get you to distinguish between a person that has renal dysfunction. In that case, you're going to use unfroxinated heparin. Versus a person that doesn't have renal dysfunction. In that case, you're going to use low molecular weight heparin, right? That's the primary treatment for PE, because most times, it will help the body have enough time to take care of the clot and deal with the issue at hand. But to be honest with you, I wouldn't go... I wouldn't say, oh, you know what, for every PE question, pick TPA, pick TPA, pick TPA, pick TPA. There are very few situations where you should pick TPA on your exams, right? And one thing I will say is, the only time you should pick TPA is when a person that has a PE and they fall into one of two categories. One is they're hemodynamically unstable. You notice the person going into shock in those circumstances. You should be giving those people TPA.

That's one. Now, the second circumstance where you should be giving TPA is where they give you clear definitive signs in the question of the person's right ventricle beginning to fail. What do I mean by that? So they will give you signs in the question like they may say that. Or an echocardiography. The person's right ventricle pressures are found to be elevated or the right ventricle is beginning to descend. In those circumstances, you need to go gangbusters and do TPA. Now, obviously there are some people that cannot even get hair printing in the first place or even TPA. And again, who are those people? The big, big thing I want you to remember are people that have had a recent surgery. A person has had a recent surgery or a person has like bleeding, right? Or they've had like a neurosurgical procedure. In those circumstances, you really should not be giving those people hair print or giving those people TPA, right? In those circumstances, especially when they have like a very bad like massive PE where they are hypotensive, they are right ventricle is failing. Really, the only thing you can do for those people is embolectomy, right? You can perform embolectomy, you can perform embolectomy. And then one other case, you may notice that today I'm just giving a lot of scenarios because that's the reason I'm giving a lot of scenarios is this is the way you really test this thing, right? One of the scenarios they can give you is they can give you a person that has a DVT, right?

And again, the person has one of these contraindications like recent because usually the prematurement of a DVT is with hair print, right? But when a person has a DVT, right? Unless they have a history of bleeding or less they have like recent neurosurgical procedure or again they've had recent surgery. In those circumstances again, you really should not be giving those people hair print for their DVT. The primary trippend of DVT in those people is to place an IVC filter, okay? It's to place an IVC filter and in fear of an akeva filter, right? Again, that's very, very, very, very high autonome, right? Very, very high autonome on, on exams. And the thing is, after a person has been treated for, for PE, do they need any further therapy like long term? Yes, the answer to that is yes, absolutely, right? Those people need to be placed on anti-qualgulation for, you know, at least three months. I'll say at the very least, after they've had that problem, they should be treated for like three months with an anti-qualgulant. And really to be honest with you, the anti-qualgulants you should use use your doox, right? Use your oral anti-qualgulants like your factor 10 inhibitors or your factor 2 inhibitors. Remember, your factor 10 inhibitors have X in their name, a pixaban, river oxaban, a doxaban, right? Your factor 2 inhibitors are things like bivaleridine, dhabigatran, agatroban, right? Those are all drugs you can use, right?

I mean, in certain circumstances, you can use warframe, right? But use warframe if those other things are not options, right? But in pretty much every other case, you should go ahead and use a user. Use these doox, right? As I call them again, they are basically factor 2 and factor 10 inhibitors. Now, one thing I would say though is, if a person is a concert patient or a person is pregnant, the only thing you should be using in those people is hairpric. That's it, right? If a person is a concert patient or the person is pregnant, the only thing you should be using in those people is hairpric. We're pretty much everyone else. You can go ahead and use those oral anti-qualgulants. So, I think those are kind of like the big things I want to talk about from the setting of a bone armbolus. Again, if you know these things I've talked about, you should be able to pretty much answer all the questions you see on your exam, or at least most of them. So, thank you for listening to me. Again, as I do at the end of a very podcast, I actually have a step 2, see case step 3 course. One is ongoing now, but obviously probably can join me anymore. But I have one in October. The one in October is going to be a test-ticking strategy course. It's pretty much going to be happening. I believe between the 4th and the 8th of October. Just email me and you'll get specific details on that. What is going to be basically the first 3 days in October is like leading to a weekend.

But that first full week of October is where we're going to have it. On the Monday of that week, we're going to have the NV Me test-ticking strategy course. And then from Tuesday to Friday, we're going to be having the review course. For step 2, see case step 3, come Lex. If you're interested, just shoot me an email. And I also do offer one on one Twitter info all the USMID exams. Step 1, step 2, see case step 3. Pretty clean cool med school exams, 30-ish off exams. And I also help with your applications and things of that nature. Again, I've worked with tons of people that I've had a lot of really good benefit from it. So if you're interested, just shoot me an email. And then I have all these podcasts on all the podcast apps. I have a website, divininginterventionpodcast.com. If you subscribe to that, whenever I make a new podcast, you get an email notification. And then I also have a You Tube channel, diviningintervention.usmilypodcasts and videos. That's where I post the videos that I make. And then finally, I have this new website called our diviningintervention, Life Lessons.com. Many people have emailed me that, oh, divining, I love your life lessons. So I kind of decided to start a website where like every week I put like two lessons, like like Life Lessons, they're kind of Bible based. And they're all less than 10 minutes long. And we just discussed a Life Lesson that I know is particularly important for people in this day and age that we live in.

So thank you for listening to me. I'll see you next time. God bless you. Thank you.

Stasis (blood not moving), Hypercoagulability (increased clotting tendency), and Endothelial Dysfunction (damage to vessel lining).

D-dimer. A normal result effectively rules out PE.

Exudative effusion (due to inflammation and increased vascular permeability).

Only in cases of hemodynamic instability (shock) or definitive signs of right ventricular failure.

Placement of an IVC filter.

DOA Cs (Direct Oral Anticoagulants), specifically Factor X inhibitors (e.g., Rivaroxaban) or Factor II inhibitors (e.g., Dabigatran).

Patients with renal dysfunction, as UFH clearance is less dependent on kidney function than LMWH.

1) Hemodynamic instability/shock, or 2) Clear signs of right ventricular failure (e.g., elevated RV pressures).

At least three months.

Exudative; due to an inflammatory cascade that increases vascular permeability.

IVC filter.

Only administer D-dimer to patients who are low clinical probability/low risk for PE.

Patients with renal dysfunction, as UFH clearance is less dependent on kidney function than LMWH.

1) Hemodynamic instability/shock, or 2) Clear signs of right ventricular failure (e.g., elevated RV pressures).

At least three months.

Exudative; due to an inflammatory cascade that increases vascular permeability.

IVC filter.

Only administer D-dimer to patients who are low clinical probability/low risk for PE.