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Pulmonary Embolism

Pulmonary Embolism

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Published by David Muniz

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Published by: David Muniz on Mar 12, 2013
Copyright:Attribution Non-commercial


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David Queiroz Borges MunizSurgical Critical CareJohn H. Stroger, Jr. Hospital of Cook CountyUniversidade Federal de Minas Gerais
A 56-year-old man presents with complaint of sudden onset of severeshortness of breath. He does not have fever, cough, chest pain, orpalpitations. He felt dizzy for a few seconds at the onset of shortnes of breath. Past medical history is significant for hypertension for 10 yearsfor wich he takes enalapril. On examination T is 98°F, HR 104/min, RR28/min, and BP 115/70mmHg. There were no orthostatic changes fromlying to the sitting position. SpO
is 94% on a nonrebreather facemask.He has no elevation of jugular venous pulse. Lungs are CTA. Heart soundsreveal normal S1 and S2 with no murmurs, S3 or S4. Abdominal exam isunremarkable and he has no cyanosis, clubbing, or edema. ChestRadiograph was normal. EKG demonstrates sinus tachycardia andinverted T waves in leads III, aVF, V2, V3 and V4. Helical CT showedpulmonary emboli completely obstructing the right pulmonary arteryand partially obstructing the left pulmonary artery. No DVT is identified.Wich one of the following is the next best step?
Heparin anticoagulation
Thrombolytic therapy followed by heparin
Thrombolytic therapy followed by heparin only if cardiacechocardiogram shows acute right ventricular strain.
Heparin anticoagulation and place of inferior vena cava (IVC) filter.
Pulmonary embolism causing hemodynamic instability is termed massive; once itis suspected, a diagnostic plan and supportive measures are essential. Thephysiological effect of massive pulmonary embolism is such that resulting rightventricular failure may lead to compromised left ventricular preload, which maybe life-threatening
The most widely accepted indication for thrombolytic therapy is provenpulmonary embolism with cardiogenic shock; therapy is also frequentlyconsidered when a patient presents with systemic hypotension without shock.
The use of thrombolysis in submassive embolism
that is, pulmonary embolismcausing right ventricular dilatation and hypokinesis without systemichypotension is debated.Clinical trials have not been sufficiently large to providedefinitive data on the survival benefit in such cases
An elevated serum troponin level may identify a subgroup of normotensivepatients who may benefit from more aggressive treatment.
Thrombolytic therapy may also be considered in patients with severelycompromised oxygenation or a massive embolic burden identified by imagingstudies
even without hemodynamic instability
or in patients with extensivevenous thrombosis that accompanies nonmassive embolism. However, theevidence base supporting these indications is inadequate, and individualized careis necessary.TAPSON, V. F. N Eng J Med 2008; 358:1037-52

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