PULMONARY EMBOLISM

Dr ABDELMONIEM SAEED
ER SPECIALIST
 Pulmonary Embolism
 It’s a complication of venous thrombosis

 second leading cause of sudden, unexpected, nontraumatic death

in outpatients.

 incidence of approximately 1 in 1500 per year

 the incidence increases with age to a maximum of 1 in 300 per

year at age 80.
 More in women and blacks than in males and whites

 lowest in Asians and Latinos.

 Presentation
 Dyspnea is the hallmark of PE
 unexplained by ausculatory findings
 ECG changes
 or obvious diagnosis on chest radiograph
 Pleuritic Chest pain
 Epigastric pain in large PE
 Tachycardia, Tachypnea and Low spo2 reading
 Mild increase in body temperature
 Clear lung on auscultation
 Heart S3 and split S2 with load S2
Factors that Can Affect the Clinical Presentation of Patients with Pulmonary Embolism (PE)

Cofactor Clinical Impact Comment

Previously healthy and young age Less severe signs and symptoms One half of previously healthy patients
with first-time PE have normal vital
sign values at diagnosis.

Prior cardiopulmonary disease Can obscure history and findings Most patients with PE and baseline
cardiopulmonary disease describe
dyspnea with PE as "worse than usual."

Patient cognitive dysfunction Causes the history to be less reliable Approximately 20% of patients with PE
missed by ED clinicians had baseline
dementia.

Clot size and location Affects severity of dyspnea, pain, and Proximal clots cause ventilation–
signs perfusion mismatch and dyspnea;
distal clots cause infarction with pain.

Gradual loading of PE Gradual onset of dyspnea and fatigue Fewer than one half of patients with PE
describe symptom onset as sudden.
ROUTINE INVESTIGATION
12-lead ECG
may demonstrate
 sinus tachycardia.
 the S1-Q3-T3 pattern (McGinn-White sign).
 T-wave inversion in leads V1 to V4,
 right bundle-branch block
ABG and Troponin

 ABG
 Low Spo2less than 94%
 Low PaO2
 Low PaCO2

 Troponin
CXR

 cardiomegaly
 nonspecific findings for PE basilar atelectasis,
infiltrate, or pleural effusion
 a wedge-shaped area of lung oligemia (Westermark
sign)
 peripheral dome-shaped dense opacification
(Hampton hump).
SPECIFIC DIAGNOSTIC
INVESTIGATION
D- dimer
 Two fibrinogen molecules produce one D-dimer unit
 half-life is approximately 8 hours
 It remains abnormally high for at least 3 days after symptomatic
VTE
 Qualitative test
 performed in about 10 to 15 minutes using whole blood
 Quantitative test
 performed in the central hospital laboratory
 The sensitivity ranges from 94% to 98%
 The specificity from 50% to 60% for PE and DVT
 Charlotte safe rule for quantitative D-dimer assay for suspected PE
patients

Safe boxes patients have a sufficiently low pretest probability to permit pulmonary
embolism to be ruled out solely on the basis of a normal quantitative D-dimer
2. CT Angiography
 Identifies a clot as a filling defect in contrast-enhanced pulmonary
arteries
 The diagnostic sensitivity and specificity is about 90% .
2. CT Angiography
Complication
1. Increased risk of radiation especially in young women because
of radiation to the breast.

2. Anaphylactoid reaction to contrast and pulmonary edema

occurring in about 1 in 1000 patients.

3. Contrast nephropathy resulting in acute renal failure requiring

hemodialysis is rare, but laboratory-defined contrast
nephropathy probably occurs in 5% to 10% of patients.

4. contrast extravasation into a limb that causes pain,

compartment syndrome, and secondary thrombophlebitis.
3. Ventilation perfusion lung scanning
 Identify a perfusion defect when ventilation is normal

 homogeneous scintillation throughout the lung in the perfusion

portion has nearly 100% sensitivity in ruling out PE.

 two or more wedge-shaped defects in the perfusion phase with

normal ventilation in these regions indicates >80% probability of
PE.

 All other scan findings are nondiagnostic and can neither rule out
nor rule in PE.
3. Ventilation perfusion lung scanning
Other Specific diagnostic investigation
 Pulmonary angiography

 Venous Us

 venography
Charlotte diagnostic algorithm for pulmonary
embolism (PE).
 Classification of P.E
Massive PE is
 PE with a systolic blood pressure of <90 mm Hg for >15
minutes.
 a systolic blood pressure of <100 mm Hg in a patient
with a history of hypertension.
 a >40% reduction in baseline systolic blood pressure.

Submassive PE is characterized by
 a normal or near-normal blood pressure.
 but with other evidence of cardiopulmonary stress

other PE
TREATMENT
Unfractionated heparin
 80 units/kg bolus, then 18 units/kg/h infusion

 A standard treatment for PE

 recommended over LMWH for submassive or massive PE, or in

situations in which SC absorption is questioned
LMWHs
Recommended over unfractionated heparin
 Clexane (enoxaparin)
100 IU/kg SC every 12 h or 200 IU/kg SC every day
 Dalteparin
1 milligram/kg SC every 12 h or 1.5 milligrams/kg SC every
day
 tinzaparin
175 IU/kg SC every day
 Thrombolytic therapy
Streptokinase
250,000 international units IV bolus, followed by 100,000 international units/h continuous IV infusion for
1–3

alteplase (Activase)
10-milligram IV bolus followed by 90 milligrams infused over 2 h

Indication of fibrinolysis
 cardiac arrest at any point

 arterial hypotension fulfilling criteria for massive PE

 respiratory failure, evidenced by

 severe hypoxemia (pulse oximetry reading <90%) despite oxygen administration
 together with evidence of increased work of breathing
 evidence of right-sided heart strain on echocardiography or elevated levels of
troponin T or I, or both .
DVT
 Clinical presentation
 The acute signs and symptoms of DVT

 varicose veins and cutaneous changes

hyperpigmentation and skin ulcers

 extremity pain, cramping.

 swelling
A difference of 2 cm between right and left leg diameter 10 cm below the tibial
tubercle

 tenderness and redness in the swollen extremity

 Evidence of thrombophlebitis
Clinical presentation
 Human's sign
 which refers to calf pain elicited by passive foot dorsiflexion and
is both insensitive and nonspecific for DVT

 compartment syndrome

 phlegmasia alba dolens

A swollen, painful, and pale or white limb with a proximal
venous thrombosis is termed, whereas is called

 phlegmasia cerulea dolens

a limb with a dusky or blue color
 Diagnostic algorithm for deep venous thrombosis (DVT). This
algorithm is to be applied in patients with leg symptoms compatible
with DVT.

 + = positive test result

 – = negative test
TREATMENT
 TREATMENT
 Unfractionated heparin

 LMWH

 Thrombolysis

 Catheter-directed thrombolysis
 Indications for Thrombolysis in D V T

 Severe DVT, that causes phlegmasia cerulea

dolens
 a very swollen, painful limb distal to a DVT
 a patient with limb compartment syndrome:
 place the affected limb at a neutral level
 remove constrictive clothing, cast, or dressing
 and begin heparin therapy