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PULMONARY EMBOLISM

“THE GREAT MASQUERADER”. PULMONARY EMBOLISM. Dr. Prakash Mohanasundaram EMERGENCY PHYSICIAN. DEFINITION. Triad: Hypercoagulability Stasis to flow Vessel injury. HYPERCOAGULABILITY Malignancy Pregnancy Postpartum status(<4 wks) Estrogen Antiphospholipid antibodies

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PULMONARY EMBOLISM

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  1. “THE GREAT MASQUERADER” PULMONARY EMBOLISM Dr. Prakash Mohanasundaram EMERGENCY PHYSICIAN

  2. DEFINITION

  3. Triad: • Hypercoagulability • Stasis to flow • Vessel injury

  4. HYPERCOAGULABILITY Malignancy Pregnancy Postpartum status(<4 wks) Estrogen Antiphospholipid antibodies Genetic mutations Factor V Leiden mutation Prothrombin gene mutation Factor VIII mutations Protein C deficiency Protein S deficiency VENOUS STASIS Bed rest >48 hrs Cast or external fixator Recent hospitalisation Long distance automobile or air travel RISK FACTORS • VESSEL INJURY • Recent surgery requiring endotracheal intubation • Recent trauma requiring hospitalisation

  5. PATHOPHYSIOLOGY • Embolization • Physiology • Right ventricular dysfunction

  6. EMBOLIZATION • Proximal leg DVT • Calf vein thrombi • Upper extremity thrombosis

  7. PHYSIOLOGY • Increased pulmonary vascular resistance • Impaired gas exchange • Alveolar hyperventilation • Increased airway resistance • Decreased pulmonary compliance

  8. DEATH “RIGHT VENTRICULAR DYSFUNCTION”

  9. Clinical Features Symptoms in Patients with Angio Proven PTE Symptom Percent Dyspnea 84 Chest Pain, pleuritic 74 Anxiety 59 Cough 53 Hemoptysis 30 Sweating 27 Chest Pain, nonpleuritic 14 Syncope 13

  10. Clinical Features Signs with Angiographically Proven PE Sign Percent Tachypnea > 20/min 92 Rales 58 Accentuated S2 53 Tachycardia >100/min 44 Fever > 37.8 43 Diaphoresis 36 S3 or S4 gallop 34 Thrombophebitis 32 Lower extremity edema 24

  11. Unexplained tachypnoea, tachycardia,Hypoxia –Suspect PTE

  12. PRETEST PROBABILITY

  13. NON IMAGING D-Dimer ELISA ABG ECG NON INVASIVE CXR Venous ultrasonography Chest CT Lung scanning MR Contrast enhanced Echocardiography DIAGNOSING MODALITIES INVASIVE • Pulmonary angiography • (GOLD STANDARD) • Contrast phlebography

  14. D-dimer Test • Fibrin split product • Circulating half-life of 4-6 hours • Positive assay > 500 ng/ml • Quantitative test have 80-85% sensitivity, and 93-100% negative predictive value • False Positives: Pregnant Patients Post-partum < 1 week Malignancy Surgery within 1 week Advanced age > 80 years Sepsis Hemmorrhage CVA AMI Collagen Vascular Diseases Hepatic Impairment

  15. ABG • Hypoxemia • Hypocarbia “ LACK DIAGNOSTIC UTILITY IN PE ”

  16. ECG • Most Common Findings: • Tachycardia or nonspecific ST/T-wave changes • Acute cor pulmonale or right strain patterns • Tall peaked T-waves in lead II (P pulmonale) • Right axis deviation • RBBB • S1-Q3-T3 (occurs in only 20% of PE patients) • Atrial fibrillation / Atrial flutter

  17. Chest X ray • Westermark’s sign focal oligemia / cut off sign • Hampton’s hump peripheral wedge shaped density above the diaphragm • Palla’s sign enlarged right descending pulmonary artery ALMOST ALWAYS NORMAL CHEST X RAY

  18. WESTERMARK SIGN

  19. HAMPTON’S HUMP

  20. PALLA’S SIGN

  21. Venous Ultrasonography Loss of vein compressibility ½ of pts with PE have no imaging evidence of DVT

  22. Chest CT • Principal imaging test • New generation multislice scanners locates thrombi in the fifth order branches • Alternative diagnosis • Pneumonia • Emphysema • Pulmonary fibrosis • Pulmonary mass • Aortic pathology

  23. V/Q SCAN

  24. NORMAL V/Q SCAN

  25. ABNORMAL V/Q SCAN

  26. MR contrast enhanced • Results similar compared with first generation CT • Also assesses right ventricular function

  27. Echocardiography • ½ pts have normal echo • DD’s • AMI • Pericardial tamponade • Aortic dissection • PE complicated by right heart failure • Risk stratification MC CONNEL’s sign – right ventricular free wall hypokinesis with normal right ventricular apical motion

  28. Pulmonary angiography(GOLD STANDARD) • Detect emboli as small as 1 to 2 mm RESERVED FOR • Technically inadequate CT scans • Scans performed on older machines • Pts who will undergo interventions

  29. Arrow indicates abrupt termination of a pulmonary artery. Www.brighamrad.Harvard.edu/cases/bwh/images. Pulmonary Embolus

  30. TREATMENT THE EMERGENCY PERSPECTIVE

  31. DICTUM “ABC”

  32. RISK STRATIFICATION

  33. PRIMARY THERAPY Thrombolysis Embolectomy ADJUNCTIVE THERAPY O2 Pain relief Dobutamine Caution – volume overload TREATMENT SECONDARY THERAPY • Anticoagulation • IVC filters Pulmonary thromboendarterctomy

  34. SCENARIO • 45 year male, case of OPC poisoning • Being treated with mechanical ventilation • Paralysed & sedated for 2 days • Develops sudden tachypnoea, tachycardia, hypotension & hypoxia

  35. WHAT IS YOUR LINE OF MANAGEMENT

  36. THROMBOLYSIS • Recombinant tPA 100 mg iv infusion over 2 hours • Streptokinase 250,000 U iv over 30 mins foll by 100,000 U/hr for 24 hrs • Urokinase 4,4OO U/kg iv over 10 mins foll by 4,000 U/kg/hr for 12 hrs • Alteplase 15 mg iv bolus foll by 2 hr infusion of 85 mg ( discontinue heparin during infusion)

  37. SCENARIO • 45 year male, A case of glioma • Underwent craniotomy & evacuation 2 days ago • Bed ridden for 2 days • Develops sudden tachypnoea, tachycardia, hypotension & hypoxia

  38. WHAT IS YOUR LINE OF MANAGEMENT

  39. EMBOLECTOMY Indicated in pts with risk of thrombolysis • Surgical embolectomy • Catheter embolectomy

  40. SCENARIO • 45 year male, case of OPC poisoning • Being treated with mechanical ventilation • Paralysed & sedated for 2 days • Develops sudden tachypnoea & tachycardia • BP - Normal

  41. ECHO NORMAL WHAT IS YOUR LINE OF MANAGEMENT

  42. Heparin / LMWH / Warfarin • Heparin 80 U/kg iv bolus foll by 18 U/kg/hr • Enoxaparin 1 mg/kg twice daily / 1.5 mg/kg daily • Tinzaparin 175 mg/kg OD • Fondaparinux <50 kg receive 5 mg, 50–100 kg patients receive 7.5 mg >100 kg receive 10 mg. • Warfarin – 2.5 to 10 mg Target INR – 2.0 TO 3.0

  43. IVC Filters • INDICATIONS • Active bleeding that precludes anticoagulation • Recurrent venous thrombosis despite intensive anticoagulation

  44. PREVENTION OF PULMONARY THROMBOEMBOLISM

  45. SUMMARY • > 50 % pts with DVT are associated with PE • > 50 % cases do not have any signs or symptoms • Common presentation can be unexplained tachycardia, tachypnoea, hypoxemia or mere anxiety • Diagnosis and suspicion is purely clinical • Follow up with anticoagulants is must as there is a increased risk of recurrence

  46. PREVENTION IS BETTER THAN CURE

  47. THANK YOU

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