Pulmonary Embolism

Fahad Al-Suwayeh (R2 Orthopedic)

:Supervised By
Dr. Rakan Al-Qahtani
 What is PE?
?Prevalence of PE
- The word "embolism" comes from the Greek
émbolos, meaning "stopper" or "plug.“
- is a blockage of an artery in the lungs by a
substance that has moved from elsewhere in
the body through the bloodstream
(embolism).
- 50,000 individuals die from PE each year in USA
- incidence of PE in USA is 500,000 per year
- 10% will die within 1 hour
- 90% will survive 30% Dx made >> 90%
survival/10%death

70% Dx not made >> 70%

survival/30%death
 Blood flow to the lungs
• Venous system from upper and lower parts of
the body drains into the right atrium and then
pumped into the right ventricle
• The right ventricle pumps blood to the lungs
Risk factors for venous
?thrombosis
 Source of emboli?
• DVT >95%
– Other veinsL
• Renal
• Uterine
• Right cardial chamber
 Risk factors for DVT
• General anesthesia
• Lower limb or pelvic injury or surgery
• Congestive heart failure
• Prolonged immobility
• Pregnancy
• Postpartum
• Oral contraceptive pills
• Malignancy
• Obesity
• Advanced age
• Coagulation problems
 Sign and Symptoms
• Sudden SOB
• Tachypnea
• Pleuritic chest pain
• Tachycardia
• Hemoptysis
 Massive Pe
• is a catastrophic entity which often results in
acute right ventricular failure and death
• Fatal PE typically leads to death within one to
two hours of the event
 Pathophysiology
• Massive PE causes an increase in PVR > right
ventricular outflow obstruction > decrease
left ventricular preload > Decrease CO
• In patients without cardiopulmonary disease,
occlusion of 25-30 % of the vascular bed >
increase in Pulmonary artery pressure (PAP)
• Hypoxemia ensues > stimulating
vasoconstriction > increase in PAP
 Pathophysiology
• More than 50% of the vascular bed has to be
occluded before PAP becomes substantially
elevated
• When obstruction approaches 75%, the RV
must generate systolic pressure in excess of
50mmHg to preserve pulmonary circulation
• The normal RV is unable to accomplish this
acutely and eventually fails
 Diagnosis
• CXR
• ABG:
– high Ph/low pCO2(tachypnea)/low pO2(V/Qmismatch)
– Resp. Alkalosis
• ECG
• V/Q:
– Decreased perfusion, but same ventilation
• SPIRAL CT
• PULMONARY ANGIOGRAM:
– Gold standard (But invasive)
• D-DIMER
• LL US
 CXR
• Most common finding
is negative CXR
– Helpful to R/O
pneumonia,
pneumothorax
 INVx
• ABG: Hypoxemia is uniformly present
• V/Q: Perfusion defect
Diagnostic strategy
 Treatment
• Dosage and monitoring of anticoagulant therapy
– After initiating heparin therapy, repeat APTT every 6 h for first
24 h and then every 24 h when therapeutic APTT is achieved
– Warfarin 5 mg/d can be started on day 1 of therapy; there is no
benefit from higher starting doses
– Platelet count should be monitored at least every 3 d during
initial heparin therapy
– Therapeutic APTT should correspond to plasma heparin level of
0.2 – 0.4 IU/mL
– Heparin is usually continued for 5 – 7 d
– Heparin can be stopped after 4 – 5 d of warfarin therapy when
INR is in 2.0 – 3.0 range
 Complications of treatment
Management Complication Med
- Stop heparin Bleeding Heparin
- If needed: reverse heparin with IV protamine

• Stop heparin HIT

• Give direct thrombi inhibitor
• Avoid Plt transfusion
- Consider LMWH Ostroporosis: if > 1 month
• Stop warfarin Bleeding Warfarin
• Give Vit-K, FFP
• Supportive care Skin necrosis
• Do not give in pregnant lady Teratogenicity
 Thromolytic
• Indications
– Hemodynamic instability
– Hypoxia on 100% oxygen
– Right ventricular dysfunction by echocardiography
• Relative Contraindications
– Recent surgery within last 10 d Previous arterial punctures within 10 d
– Neurosurgery within 6 mo Bleeding disorder (thrombocytopenia, renal failure,
liver failure)
– Ophthalmologic surgery within 6 wk
– Hypertension >200 mm Hg systolic or 110 mm Hg diastolic Placement of central
venous catheter within 48 h
– Hypertensive retinopathy with hemorrhages or exudates Intracerebral aneurysm
or malignancy
– Cardiopulmonary resuscitation within 2 wk
– Cerebrovascular disease
– Major internal bleeding within the last 6 mo Pregnancy and the 1st 10d
postpartum
– Infectious endocarditis Severe trauma within 2 mo
– Pericarditis
• Absolute contraindication
– Active internal bleeding
IVF filters
 Indications for inferior vena caval filter placement

• Anticoagulation contraindicated (eg, patients with multiple

trauma, active bleeding)
• Failure of antithrombotic therapy
• Complications from anticoagulant therapy preclude further
use
• Prophylaxis against embolism from preexisting deep vein
thrombosis in patients with poor cardiopulmonary reserve
• Prophylaxis against embolism in patients at high risk to
develop deep vein thrombosis
• Patients with recurrent pulmonary embolism undergoing
thromboendarterectomy
 Take home message
• PE is common serious medical problem
• Early Dx and management is essential
• High index of suspecion is needed
 Refrences
- Pulmonary embolism, part I: Epidemiology, risk factors
and risk stratification, pathophysiology, clinical
presentation, diagnosis and nonthrombotic pulmonary
embolism
- Excluding pulmonary embolism at the bedside without
diagnostic imaging: management of patients with
suspected pulmonary embolism presenting to the
emergency department by using a simple clinical
model and d-dimer.
- Clinical characteristics of patients with acute
pulmonary embolism: data from PIOPED II.