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” قالوا سبحانك لا علم لنا إلا ما علمتنا إنك أنت العليم الحكيم ” صدق الله العظيم ( البقرة –32)

بسم الله الرحمن الرحيم. ” قالوا سبحانك لا علم لنا إلا ما علمتنا إنك أنت العليم الحكيم ” صدق الله العظيم ( البقرة –32). Pulmonary Thrombo embolism. Prof. Magd Mohamed Galal Al-Azhar University for girls Cairo 2007. Pulmonary Thromboembolism.

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” قالوا سبحانك لا علم لنا إلا ما علمتنا إنك أنت العليم الحكيم ” صدق الله العظيم ( البقرة –32)

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  1. بسم الله الرحمن الرحيم ”قالوا سبحانك لا علم لنا إلا ما علمتنا إنك أنت العليم الحكيم ”صدق الله العظيم ( البقرة –32)

  2. Pulmonary Thrombo embolism Prof. Magd Mohamed Galal Al-Azhar University for girls Cairo 2007

  3. Pulmonary Thromboembolism • 5 million patients per year in U.S. have DVT - about 30% will have symptomatic and an additional 30% will have asymptomatic PE. • PE accounts for about 50,000 deaths in the United States per year • a) fatality rates: • if PE recognized and treated: mortality = 2.5% • if PE unrecognized and not treated: mortality = 30% b) PE accounts for 15% of post-operative deaths & 10-20% of all in-hospital deaths • C) 20% of patients with PE will die of other medical conditions within 1 year of the diagnosis of PE with cancer & infection the most common causes of death • Pulmonary embolism is likely the most common preventable cause of hospital deaths

  4. Objectives • Identification of the high risk patients. • Prophylaxis to prevent DVT. • Diagnostic approach in suspected VTE. • Treatment of acute PTE.

  5. DVT: Unilateral leg swelling Leg pain/tenderness - may increase with walking, standing, or exertion. warmth in the leg Bluish or reddish skin discoloration Clinical Presentation • PE: • Dyspnea/tachypnea • Tachycardia • Fever • Cough/hemoptysis • Hypotension • Syncope

  6. Clinical Presentation • Acute massive • Acute pulmonary infarction. • Pulmonary embolism without infarction. • Multiple pulmonary embolism.

  7. Differential Diagnosis of PE • Acute myocardial infarction. • Aortic dissection. • Acute pneumothorax. • Pneumonia.

  8. Virchow’s Triad • Hypercoagulability • Endothelial injury • Venous flow disturbance (stasis or turbulence)

  9. 1.Venous stasis. Prolonged L.L. immobility. Bed rest. Surgery. Pregnancy. C.H.F. 2.Endothelial injury Previous D.V.T. Femoral I.V.catheter. Hip surgery. Strenuous muscle activity. 3.Hypercoagulability. a) Primary: Factor V leiden mutation Hyperhomocysteinemia Prothrombin G-A20210 gene variant. Protein C&S deficiencies. Antithrombin III deficiency. b) Secondary: Antiphospholipid antibody. Malignancies. Heparin induced thrombocytopenia(H.I.T) Risk Factors

  10. Venous Thrombosis After Long-haul Flights • “Long-haul flights of 8 hours and longer double the risk for isolated calf muscle venous thrombosis in patients with other risk factors. “ Schwarz et. Al., Arch Intern Med. 2003;163:2759-2764.

  11. Approaches to clinical assessment of pulmonary embolism • Empirical clinical assessment • Standardized clinical assessment

  12. PREDICTING THE PROBABILITY OF PE • S/S of DVT 3 PTS • Alternative diagnosis deemed less likely than PE 3 PTS • Immobility or surgery in the previous 4wks 1.5 PT • HR >100 1.5 PT • Previous DVT/PE 1.5 PT • Hemoptysis 1.0 PT • Cancer 1.0 PT Low Probability < 2.0 Intermediate 2.0-6.0 High > 6.0 Frost: Mayo Clin Proc, Volume 78(11).November 2003.1385-1391

  13. clinical assessment, either empirical or standardized, can stratify patients' probability of having pulmonary embolism. The prevalence of pulmonary embolism is expected to be 10% in patients with a low clinical probability, about 25% in the intermediate-probability group and 60% in the high clinical probability group.

  14. PE is very common and potentially life threatening The presenting symptoms, signs and routine studies are nonspecific The clinician needs ahigh index of suspicion Idealdiagnostic study for PE image pulmonary vascular have high sensitivity and specificity low morbidity inexpensive Diagnostic studies for PE

  15. Chest X Ray • Nonspecific Chest XRay changes in 85% • Elevated hemidiaphragm (50%) • Hampton's Hump • Pleural based infiltrate pointed towards hilum • Westmark Sign • Dilated proximal vessels with a distal cutoff • Pleural Effusion • Atelectasis • Rules out other Dyspnea Causes • Pneumothorax • Pneumomediastinum • Aortic Dissection • Pneumonia

  16. Normal Chest XRayIn Acute Dyspnea And Hypoxemia Suggests Pulmonary Embolism If No Wheezing

  17. PULMONARY EMBOLUS AND INFARCT RIGHT LOWER LOBE

  18. PULMONARY INFARCT Peripheral, lower lobe, abuts the diaphragm

  19. LATERAL VIEW PULMONARY EMBOLUS WITH INFARCTION

  20. Abuts the pleura PULMONARY EMBOLUS WITH INFARCTION

  21. Hampton’s Hump

  22. Westermark’s Sign

  23. Atelectic band in right lower lobe representing a pulmonary infarct

  24. a wedge shaped sub pleural opacity in the correct lower lobe with its apex to the hilum representing a pulmonary infarct

  25. ECG • Nonspecific • Per UPET*, 87% sensitivity, 32% specific • S1 Q3 T3 pattern • right bundle branch block • P-wave pulmonale • right axis deviation • TWI in V1-V4 * Urokinase in PE Trial

  26. ECG changes in acute pulmonary embolism

  27. Echocardiography Identification of RV dysfunction (sub massive PE) in absence of shock (massive PE) make a difference in patient management. RV/LV end diastolic diameter ratio > 0.6 Hamel et al 2001 do not support the indication of thrombolysis in patients suffering from massive PE with stable haemo-dynamics & RV dysfunction.

  28. Arterial blood gases A-a gradient increased in 95 % of patients with proven PE. A-a gradient = Normal = 4 +(age/4) • Hypoxemia and elevated A-a gradient may be present, but PaO2 and A-a gradient may be normal, especially in young patients with normal pulmonary function. • In proven PE: • PaO2 > 80mmHg in 29% under 40 years old. • A-a gradient increase < 20mmHg in 14% under 40 years old.

  29. Plasma D-dimer level • D-dimer assays detect the presence of plasmin-mediated degradation Products Indicates: • Activation of coagulation pathways • Impairment in the elimination of fibrin degradation products. Normal D-dimer level have a high negative predictive value in excluding P.E. • 21% of cancer patients with a normal D-dimer had a DVT compared to 3.5 %of patients without cancer. • Can be elevated in pregnancy, inflammation, advanced age, trauma

  30. Measurements of steady state end Tidal Alveolar Dead Space Fraction (AVDSf) <0.15 excluded PE The combination of negative D-dimer result and a steady state end-tidal alveolar dead space fraction AVDSf of < 0.15 excluded PE with a sensitivity of 97.8% and a negative predictive value of 98%.

  31. Ventilation/Perfusion Scan

  32. Posterior view Right lung Left lung NORMAL VENTILATION SCAN Swallowed agent in stomach

  33. NORMAL PERFUSION SCAN Right lung Left lung Posterior view

  34. Normal V-P scan

  35. Process Followed to Diagnose PE

  36. ABNORMAL PERFUSION SCAN RIGHT LOWER LOBE PE Posterior Anterior No uptake (perfusion) posterior base of right lung Right lateral view

  37. Abnormal VQ Lung Scan - Ventilation Perfusion mismatch in lower right lobe

  38. Lung Perfusion Scan - Right lung occluded

  39. Abnormal VQ Lung Scan-multiple perfusion defects in both lungs

  40. High probability > = 2 large segmental perfusion defects (SPD) 1 large SPD and >= 2 moderate SPD > = 4 moderate SPD Intermediate probability 1 moderate SPD Corresponding V/Q defect and CXR opacity in lower lung Single moderately matched V/Q defect Low probability Multiple matching V/Q defects Corresponding V/Q defects and CXR parenchymal opacity in upper or middle lung zone > 3 small SPD Very low probability < = 3 small SPD Normal No perfusion defects and perfusion outlines the shape of the lung seen on CXR PIOPED Criteria *CXR = Chest Radiograph **V/Q = Ventilation-Perfusion

  41. Ventilation/perfusion scan -A high probability--------------- P.E. -Low probability ----------------exclude P.E. -An intermediate probability----duplex or I.P.G for D.V.T. or pulm angiogram. -Ventilation defects can accompany pulmonary arterial embolization for up to 48 hrs. - Patients with COPD are more likely to have intermediate scans.

  42. V/Q SCAN • 70% of patients have an indeterminate result and need another test to make the diagnosis • Good in the presence of a normal chest radiograph • Not helpful in the presence of an abnormal chest radiograph, in patients with COPD or cardiac disease • Does not provide an alternative diagnosis

  43. SPIRAL CT • Replacing V/Q scan • More accessible • More specific • As sensitive as V/Q • May miss sub segmental emboli • Requires a high dose of injected contrast (dye) - check creatinine • Diagnostic even in the presence of an abnormal chest radiograph Provides alternative diagnosis in 30% of cases

  44. SPIRAL CT FOR PE Embolus to right upper lobe pa Gray embolus left pulmonary artery

  45. SPIRAL CT FOR PE PE to right pa PE to left lower lobe pa

  46. right pulmonary artery embolus & RT pl. effusion

  47. Large calcified clot in RT pulmonary artery

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