Pulmonary embolism

created by PhD, Assistant of the Department of Internal medicine №2, clinical immunology and
allergology named after academician L.T.Malaya
Tetiana Zaikina
 Acute pulmonary embolism is a sudden occlusion of the
pulmonary artery because of venous thromboembolism or
non-thrombotic emboli leading to the cessation of blood
flow to the lung parenchyma and to the acute life-
threatening but potentially reversible right ventricular
failure.
Etiology
Pathogenesis
 Clinical symptoms

50% 39% 24% 23%

15% 8% 6% 6%
 Objective data
• Jugular veins distention
• Gallop rhythm at lower sternum
• Widely split second heart sound
• Hypotension
• Tachycardia
• Cyanosis
• Pleural friction rub
• Crackles and wheezes
Wells score
Revised Geneva score
Diagnostic algorithm for patients with suspected non high-risk PE
Diagnostic algorithm for patients with suspected high-risk PE
 Pulmonary angiography
• PA is used to be the gold
standard for the diagnosis or
exclusion of PE

• It offers similar diagnostic

accuracy as CTPA but it is
significantly more invasive

• It is still used to guide

percutaneous catheter-directed
treatment of acute PE
 CT pulmonary angiography

• CTPA is the method of choice for

imaging the pulmonary
vasculature in patients with
suspected PE

• It gives adequate visualization of

the pulmonary arteries down to
at least the segmental level non-
invasively
 Echocardiography
• RV enlargement
• McConnell's sign (decreased
contractility of the RV free
wall compared with the RV
apex)
• RV ejection pattern (so-
called “60-60 sign”)
• New onset tricuspid valve
regurgitation

“60-60 sign”: coexistence of the right ventricular outflow tract acceleration time (AT <60 ms) with a
pulmonary arterial systolic pressure (PASP) of less than 60 mmHg (but more than 30 mmHg)
 Electrocardiography

• Classic pattern SIQIIITIII

• New onset RBBB
• Sinus tachycardia
• Right axis deviation
• ST-segment deviation and T-
wave changes in V1-V4, II, III,
AVF
Compression venous ultrasonography
 Ventilation-perfusion scintigraphy
• The test is based on the i/v injection
of Tc-99m-labelled macroaggregated
albumin particles, which block a
small fraction of the pulmonary
capillaries and thereby enable
scintigraphic assessment of lung
perfusion in combination with
ventilation studies
• In acute PE there is a mismatch
between normal ventilation and
hypoperfusion of pulmonary
segments
Pulmonary embolism Pneumonia
 D-dimer test
• Should be performed in patients
with low and intermediate clinical
probability of PE due to its high
negative predictive value

• Helps to exclude PE

• Can not be used for the

confirmation of PE due to its low
specificity
 Chest X-ray

• Westermark’s sign (focal

oligemia)
• Palla’s sign (prominent right
descending pulmonary
artery)
• Triangular pulmonary
infiltrate

Focal oligemia in the right lung (area between white arrows),

prominent right descending pulmonary artery (black arrow)
PESI (Pulmonary embolism severity index) score
Clinical classification of acute PE
 Treatment of acute pulmonary embolism
• Hemodynamic and respiratory support

• Pharmacological reperfusion

• Percutaneous catheter-directed treatment

• Surgical embolectomy

• Venous filter implantation

 Pharmacological reperfusion

• High risk PE → Thrombolysis → Anticoagulation → NOAC

• Intermediate risk PE → Anticoagulation → NOAC

• Low risk PE → NOAC

 Thrombolysis

Name Dosage

Streptokinase 250000 IU as a loading dose over 30 min, followed

by 100000 IU/h over 12-24 hours
Accelerated regimen: 1,5 million IU over 2 hours
Urokinase 4400 IU/kg as a loading dose over 10 min, followed
by 4400 IU/kg per hour over 12-24 hours
Accelerated regimen: 3 million IU over 2 hours
Recombinant tissue 100 mg over 2 hours or 0,6 mg/kg over 15 minutes
plasminogen activator (maximum dose 50 mg)
Anticoagulation
 Novel oral anticoagulants (NOAC)

Name Dosage

Rivaroxaban 15 mg twice daily for 3 weeks then 20 mg once daily

Dabigatran 150 mg twice daily (110 mg twice daily if age˃80)

Apixaban 10 mg twice daily for 7 days then 5 mg twice daily

Edoxaban 60 mg once daily (30 mg once daily if eGFR˂50 ml/min)