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Pulmonary embolism

Pulmonary embolism. Pulmonology Refresher Course 27 May 2011 Dr. JM Nel Department of Critical Care. Incidence. Pulmonary embolism (PE) In 1% of patients admitted to hospital Accounts for 5% of in hospital deaths Common mode of death Cancer Stroke

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Pulmonary embolism

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  1. Pulmonary embolism Pulmonology Refresher Course 27 May 2011 Dr. JM Nel Department of Critical Care

  2. Incidence • Pulmonary embolism (PE) • In 1% of patients admitted to hospital • Accounts for 5% of in hospital deaths • Common mode of death • Cancer • Stroke • Most common cause of death in pregnancy

  3. Majority (75%) Propagation of lower limb DVT Other (rare) Amniotic fluid Placenta Air Fat Tumour Septic emboli (from endocarditis affecting tricupid or pulmonary valves) Etiology

  4. Surgery Major abdominal/ pelvic surgery Hip/ knee surgery Post- operative intensive care Obstetrics Pregnancy/ puerperium Cardiorespiratory disease COPD Congestive cardiac failure Other disabling disease Lower limb problems Fracture Varicose veins Stroke/ spinal injury Malignant disease Abdominal pelvic Advanced/ metastatic Concurrent chemotherapy Miscellaneous Increasing age Previous proven VTE Immobility Thrombotic disorders Trauma Risk factors

  5. Clinical features • Clinical features vary DIFFICULT DIAGNOSIS

  6. Clinical features ASK 3 QUESTIONS • Is the presentation consistent with PE ? • Does the patient have risk factors for PE ? • Is there another diagnosis that can explain the patients presentation ?

  7. Clinical features • Clinical features • Acute massive PE • Submassive PE • Acute small/ medium PE

  8. Symptoms Collapse Central chest pain Severe dyspnoea Signs Major circulatory collapse Tachycardia Hypotension Increased JVP Loud P2 Parasternal heave RV gallop rhythm Severe cyanosis Acute massive PE

  9. Symptoms Pleuritic chest pain Restricted breathing Haemoptysis Signs Tachycardia Pleural rub Raised hemidiaphragm Crackles Effusion Low- grade fever Normal BP Acute small/medium PE

  10. Submassive PE WHAT’S THAT ???

  11. Submassive PE • Massive PE • RV Strain/dilatation • Low BP • Submassive PE • RV Strain/dilatation • Normal BP

  12. CXR ECG Arterial blood gas D- dimer Heart sonar Other biomarkers Imaging Investigations

  13. Investigations: Chest x- ray • High index of suspicion if normal CXR • Acute dyspnoec and hypoxemic patient • Exclude differential diagnoses • Heart failure • Pneumonia • Pneumothorax

  14. Radiographic appearances Pulmonary opacities Wedge shaped opacity Horizontal linear opacities Pleural effusion Oligaemia of lung field Enlarged pulmonary artery Elevated hemidiaphragm Investigations: Chest x- ray

  15. Investigations: Chest x- ray • Acute massive PE • Usually normal • Oligaemia • Acute small/ medium PE • Pleuropulmonary opacities • Pleural effusion • Linear shadows • Raised hemidiaphragm

  16. Investigations: ECG • Common but non- specific • Most common • Sinus tachycardia • Exclude other differential diagnoses • Acute myocardial infarction • Pericarditis

  17. Massive/Submassive PE Acute corpulmonale S1 Q3 T3 T- wave inversion RBBB P-wave pulmonale Right axis Small/ medium PE Sinus tachycardia Investigations: ECG

  18. Investigations: A- blood gas • Typical A- blood gas • Low PaO2 • Normal or low PaCO2

  19. Degradation product Positive D- dimer High negative predictive value Screening test for PE ELISA based D-dimer superior sensitivity Other causes for elevation Myocardial infarction Pneumonia/Infection Sepsis Pregnancy Malignancy Hospitalised patients Elderly Trauma Investigations: D- dimer

  20. Massive/Submassive PE Acute dilatation of the right heart Pulmonary hypertension Thrombus can be seen LOOK FOR: RV DYSFUNCTION Investigations: Heart sonar • RV DYSFUNCTION • RV enlargement • Hypokinesis of free wall • Leftward septal shift • PHT

  21. Investigations: Other biomarkers • Cardiac troponin • Risk stratification • Elevated in massive PE • 6-12 hours after symptoms • Pro-BNP • Increases with ventricular stretching • But also elevated in other causes of PHT/congestive heart failure Detects myocardial injury Detects myocardial dysfunction

  22. Investigations: Other biomarkers • Normal levels: • Low risk of death/complications • Increased levels: • Cannot predict early death • RISK ASSESSMENT • Do not dictate need for early thrombolysis

  23. Investigations: Imaging • V/Q scans • If normal • Excludes PE • If underlying chronic cardiopulmonary pathology (COPD, congestive cardiac failure) • Majority of scan indeterminate

  24. Investigations: Imaging • CT pulmonary angiography • Difficult to detect small peripheral emboli • Duplex doppler of legs • DVT in leg • Pulmonary angiography • Gold standard

  25. Management • General measures • Anticoagulation • Thrombolytic therapy • Caval filters

  26. Oxygen for hyoxaemic patients Keep arterial oxygen saturation > 90% Analgesics Opiates Careful in hypotensive patients Avoid diuretics and vasodilators Treat hypotension IVI fluids Inotropic agents of limited value Management: General

  27. Confirmed PE ECHO RV dysfunction NO YES Hemodynamically Stable ? Low risk Non-massive PE NO YES Massive PE Anticoagulate Submassive PE UFH LMWH Thrombolysis if no contra-indication Anticoagulate

  28. Start immediately High or intermediate probability of PE Low molecular weight heparin sc Clexane Give according to weight Reduces mortality in PE Reduces the propagation of clot and risk of further emboli Give at least 5 days Start Warfarin Stop Clexane when INR is > 2 Management: Anticoagulation

  29. Management: Anticoagulation • Duration of Warfarin therapy • If underlying prothrombotic risk or previous emboli • For life • If identifiable and reversible risk factor • 3 Months • If idiopathic • 6 Months

  30. Management: Thrombolytic therapy • Acute massive pulmonary embolism • Patient shocked • Improves outcome • If normal BP • Unsure if advantage above heparin • High risk of intracranial haemorrhage • Screen patient for haemorrhagic risk

  31. Management: Caval filters • Filter inserted in inferior vena cava • Below origin of renal vessels • Indications • Recurrent PE despite adequate anticoagulation • Contraindication to anticoagulation

  32. Prognosis • Lowest recurrence after operation • If right ventricular dysfunction • Risk of cardiogenic shock • Increased risk of death • If pulmonary hypertension and right ventricular dysfunction after 6 weeks • Increased risk to develop right heart failure over next 5 years

  33. Pulmonary Embolism:Case Studies

  34. Pulmonary embolism • Case Presentation 1: • 64 year old male • Previous hip surgery 20 days ago • Sudden dyspnoea • Pleuritic chest pain • Hypoxic • BP 130/80 • Clinically DVT

  35. Pulmonary embolism DIFFERENTIAL DIAGNOSIS • Pulmonary embolism • Pneumonia • Pneumothorax • Musculoskeletal chest pain

  36. Pulmonary embolism ASK 3 QUESTIONS • Is the presentation consistent with PE ? • Does the patient have risk factors for PE ? • Is there another diagnosis that can explain the patients presentation ?

  37. Pulmonary embolism WHAT NOW ???

  38. Pulmonary embolism • CXR • Exclude differential diagnoses • Heart failure • Pneumonia • Pneumothorax • High index of suspicion if normal CXR • Acute dyspnoeac and hypoxaemic patient

  39. Pulmonary embolism • ECG • Exclude other differential diagnoses • Acute myocardial infarction • Pericarditis • Most common • Sinus tachycardia

  40. Pulmonary embolism • Arterial bloodgas • Low PaO2

  41. Pulmonary embolism • D- dimer • POSITIVE

  42. Heartsonar NORMAL Massive/Submassive PE Acute dilatation of the right heart Pulmonary hypertension Thrombus can be seen Alternative diagnoses Left ventricular failure Aortic dissection Pericardial tamponade Pulmonary embolism

  43. Pulmonary embolism • Duplex doppler of legs • DVT in leg

  44. Pulmonary embolism • V/Q scan • PULMONARY EMBOLISM

  45. Pulmonary embolism: Management • General measures • Oxygen for all hyoxaemic patients • Keep arterial oxygen saturation > 90% • Anticoagulation • Clexane 80mg bd sc • Give at least 5 days • Warfarin • Stop Clexane when INR is > 2

  46. HOW LONG DO I TREAT THIS PATIENT WITH WARFARIN ??? 3 Months Duration of Warfarin therapy If underlying prothrombotic risk or previous emboli For life If identifiable and reversible risk factor 3 Months If idiopathic 6 Months Pulmonary embolism: Management

  47. Pulmonary embolism • Case Presentation 2: • 28 year old lady • Oral contraceptives • 10 hour flight • Sudden dyspnoea • BP 90/40 • Loud P2/ Increased JVP • Hypoxic

  48. Pulmonary embolism DIFFERENTIAL DIAGNOSIS • Massive pulmonary embolism • Myocardial infarction • Pericardial tamponade • Aortic dissection

  49. Pulmonary embolism • CXR • NORMAL

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