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PULMONARY EMBOLISM

PULMONARY EMBOLISM. PROF. DR. YESARİ KARTER. Pulmonary Embolism: Impaction of material into branches of the pulmonary arterial bed. Mortality- 50 000 death/year (decreasing) Hospitalisation: 300-600 000/year

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PULMONARY EMBOLISM

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  1. PULMONARY EMBOLISM PROF. DR. YESARİ KARTER

  2. Pulmonary Embolism: Impaction of material into branches of the pulmonary arterial bed

  3. Mortality- 50 000 death/year (decreasing) Hospitalisation: 300-600 000/year Male>Female American Africans old > young

  4. RISK FACTORS - inherited - acquired

  5. Inherited Risk Factors Family History (+) Acquired risk factor (-) Prior deep venous thrombosis

  6. Inherited Risk Factors (2) -Antithrombin III deficiency -Protein C deficiency -Protein S deficiency -Protein C resistance (Factor V Leiden) -Hyperhomocystinemi -Abnormal fibrinogen -Abnormal fibrinolytic system

  7. Acquired Risk Factors -surgery or trauma of pelvis/lower extremities -immobilization -surgery with >30 min general anesthesia -local tissue trauma and vessel destruction -pregnancy especialy in the puerperism and after cesarian section -estrogen therpy

  8. Acquired Risk Factors (II) -Age > 40 -Malignity -Obesity -Heart Failure -Myocard infarction

  9. Acquired Risk factors (III) -Prior DVT -Nephrotic Syndrome -Antiphospholipid Syndrome -PNH -Waldenström

  10. Thromboembolic risk of the patient -Risk of the patient (acquired / inherited) -Risk of the clinical condition

  11. Diagnose -Young patient -Family history (+) -Acquired risk factors (-) ___ inherited

  12. Symptoms -Chest pain -Pleuritic pain -Dyspnea -Cough -Hemoptysis -Syncope

  13. Laboratory Standart test ECG Chest rontgenography Arterial blood gases Echocardiography Imaging venous thrombus Imaging pulmoner emboli

  14. Standart tests -Leucocytosis (infarctuse) -ESR increases -D-Dimer increases low---- Exclusion of PE

  15. ECG Nonspesific changes -Massive emboli-----RV load Differential diagnosis -Myocardial infarctuse -Accelere atrial rythm Typical findings -RV strain -T (-) and or ST elevation (V1-3) -P pulmonale (right axis) -S1Q3T3

  16. Chest Radiography Usually nonspesific Not sensitive or specific Proximal, large segmental artery Multiple small segmental artery

  17. Chest Radiography (II) -Atelectasis -Elevation of the hemidiaphragm -Pleural efusion -Dilatation of the main branches of PA -Paranchymal densities (in the lower lung fields, pleural based) -Zones of oligemia

  18. Arterial Blood Gases Acute PaCO2 decreases Massive PaO2 decreases Submassive Normal / Nearnormal

  19. Echocardiography -Shows emboli in main pulmonary arteries, but not in lober and segmentary arteries -Dilated hypokinetic RV -Distorsion of the interventricular septum in diastole -Tricuspid regurgitation associated with increase in systolic pressure in pulmonary artery

  20. Deep Vein Thrombosis -90% of PE originates from DVT (poplitea or proximal leg veins) -leg pain or swelling -Homan’s sign -signs of infection in subcutan veins

  21. Deep Vein Thrombosis -Phlebography -Doppler

  22. Imaging pulmonary emboli -Chest radiography -Ventilation-Perfusion Lung Scan -Pulmonary angiography -hCT -MR angiography

  23. Ventilation-Perfusion Lung Scan Perfusion (-) and Ventilation (+) ---PE Perfusion (N) and Clinical sym and signs (N) ----PE excluded Low probability PVLS and low probability of clinical sym and signs ----PE excluded High probability PVLS and high probability of clinical symp and signs ---- Anticoagulation

  24. Clinical Probability of acute PE -High Probability (80-100%) Risk factors (+) Dyspnea Tachypnea Chest pain Radiology (+) PaO2 decreases P (A-a)O2 increases -Intermediate Probability (20-79%) -Low Probability (1-19%) Risk Factors (-) Clinical and laboratory findings can be explained

  25. Dichotomous clinical probability assesment: • PE likely > 4 • Pe unlikely < 4 or = 4

  26. PE likely--------h CT • ------normal----exclude • ------findings (+)----PE • ------indeterminate----LE US • PA • PE unlikely-----D-dimer(+) • -------h (CT) • D-dimer(-) • -------exclude PE

  27. Pulmonary Angiography Gold standart İmages PE in subsegmental and peripheral arteries

  28. hCT -two dimensional angiographic image -specifity 90% -dimension of the emboli -mediastinal and parenchymal patologies

  29. MR Angiography Sensitivity-70 – 90 % Specifity- 77 – 100 % (Central arteries) Also asseses RV function

  30. Treatment -to prevent death -to reduce morbidity -to prevent pulmoner hypertension progresing due to thromboemboli

  31. Treatment (II) Supportive -Oxygen -IV liquid -Vasopressors

  32. Anticoagulation -unfractioned heparin -LMWH -Thrombolysis -Embolectomy

  33. Unfractioned Heparin IV 5000 U bolus + 30-35 000 U/kg aPTT- twice the control value -Thrombocytopeni early: thrombocyte agregation slight, reveresible, no need to stop late: antibodies against trombocytes arterial and venous thromboemboli -Osteopeni

  34. LMWH -long acting -less binding to plasma protein -greater bioavailibity -no need monitorisation

  35. Prognosis -Mortality rate – 30% -Depends on associated pathology -Resolution – 5 days 36% 2 weeks 52% 3 months 73% Pulmonary hypertension recurrent microemboli (rare)

  36. Secondary prevention UFH + oral anticoagulan (6 months) LMWH SC + oral anticoagulan (6 months ) LMWH (pregnancy) Recurrance / unknown origin / permanantly increased risk (throughout life)

  37. Thrombolysis Massive pulmoner emboli with hemodynamic instability -streptokinase -urokinase -t-PA **serious bleeding

  38. REFERENCES: • Agnelli G. Anticoagulation in thepreventionandtreatment of pulmonaryembolism.Chest 1995. 107;39-44. • BellWR,Simon TL; DeMets DL. Theclinicalfeatures of massiveandsubmassivepulmonaryembolism. Am J Med 1977; 62: 355-360. • Braunwald E. Pulmonaryembolism. Braunwald’sheartdisease. Braunwald (ed)Philedalphia. WB Saunders 1992 .562-1568. • Herold CJ, Bankier AA, Burghaiber OC, Minar E, Watzke HH. PulmonaryEmbolism. ComprehensivePulmonaryMedicine. Albert R, Spiro S, Jett J (eds). HarcaurtBraceandCompanyLimitedLondon 1999. 50.1-50.12 • Hyers TH . Diagnosis of pulmonaryembolism. Thorax 1995; 50: 930-932. • Lane D, Manucci PM, Bauer KA, et al. Inheritedthrombophilia: Part I.ThrombHaemost 1996;76: 651-662. • Remy -Jerden M, Remy J,Deschildre F. Diagnosis of pulmonaryembolismwith spiral CT: comparisonwithpulmonaryangiographyandscintigraphy. Radiology 1996; 200(3):699-706.

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