pulmonary embolism n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Pulmonary Embolism PowerPoint Presentation
Download Presentation
Pulmonary Embolism

Loading in 2 Seconds...

play fullscreen
1 / 70

Pulmonary Embolism - PowerPoint PPT Presentation


  • 135 Views
  • Uploaded on

Pulmonary Embolism. Prof. Ahmed BaHammam, FRCP, FCCP Professor of Medicine College of Medicine King Saud University . Phlegmasia cerulea dolens Venous gangrene. Color duplex scan of DVT. Venogram shows DVT. Patient with suspect symptomatic Acute lower extremity DVT.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Pulmonary Embolism' - marcie


Download Now An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
pulmonary embolism

Pulmonary Embolism

Prof. Ahmed BaHammam, FRCP, FCCP

Professor of Medicine

College of Medicine

King Saud University

slide5

Patient with suspect symptomatic

Acute lower extremity DVT

negative

Venous duplex scan

Low clinical probability

observe

High clinical probability

positive

negative

Evaluate coagulogram /thrombophilia/ malignancy

Repeat scan /

Venography

IVC filter

Anticoagulant therapy

contraindication

yes

No

pregnancy

LMWH

OPD

LMWH

+ warfarin

hospitalisation

UFH

Compression treatment

thrombophilia screening factor v leiden prot c s deficiency antithrombin iii deficiency
Thrombophilia screeningFactor V leiden, Prot C/S deficiency Antithrombin III deficiency
  • Idiopathic DVT < 50 years
  • Family history of DVT
  • Thrombosis in an unusual site
  • Recurrent DVT
recommendation for duration of warfarin
Recommendation for duration of warfarin
  • 3-6 months first DVT with reversible risk factors
  • At least 6 months for first idiopathic DVT
  • 12 months to lifelong for recurrent DVT or first DVT with irreversible risk factors

malignancy or thrombophilic state

catheter directed thrombolysis
Catheter directed-thrombolysis
  • Consider in: Acute< 10 days iliofemoral DVT.
  • Long-term benefit in preventing post-phebitic syndrome is unknown.
slide10
50,000 individuals die from PE each year in USA
  • The incidence of PE in USA is 500,000 per year
slide11

Incidence of Pulmonary Embolism Per Year in the United States*

Total Incidence 630,000

89%

11%

Survival >1hr

563,000

Death within 1 hr

67,000

71%

29%

Dx not made

400,000

Dx made, therapy

instituted 163,000

*Progress in Cardiovascular Diseases, Vol. XVII, No. 4 (Jan/Feb 1975)

70%

30%

92%

8%

Survival

280,000

Death

120,000

Survival

150,000

Death

120,000

risk factor for venous thrombosis
Risk factor for venous thrombosis
  • Stasis
  • Injury to venous intima
  • Alterations in the coagulation-fibrinolytic system
source of emboli
Source of emboli
  • Deep venous thrombosis (>95%)
  • Other veins:
    • Renal
    • Uterine
    • Right cardiac chambers
risk factors for dvt
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
clinical features
Clinical features
  • Sudden onset dyspnea
  • Pleuritic chest pain
  • Hemoptysis
  • Clinical clues cannot make the diagnosis of PE; their main value lies in suggesting the diagnosis
massive pulmonary embolism
Massive Pulmonary Embolism
  • It is a catastrophic entity which often results in acute right ventricular failure and death
  • Frequently undiscovered until autopsy
  • Fatal PE typically leads to death within one to two hours of the event
pathophysiology
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
pathophysiology1
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
Diagnosis
  • CXR
  • ABG:
  • ECG
  • V/Q
  • Spiral CT
  • Echo
  • Angio
  • Fibrin Split Products/D-dimer
diagnosis1
Diagnosis

The diagnosis of massive PE should be explored whenever oxygenation or hemodynamic parameters are severely compromised without explanation

  • CXR
  • ABG:
      • Significant hypoxemia is almost uniformly present when there is a hemodynamically significant PE
  • V/Q
  • Spiral CT
  • Echo
  • Angio
diagnosis2
Diagnosis
  • D-Dimer
  • BNP
  • Troponin
slide34

Before

After

slide44

Before

After

slide50

Sensitivity of spiral computed tomography, magnetic resonance angiography, and real-time magnetic resonance angiography, for detecting pulmonary emboli

Reader

1

2

Mean

K

CT

72.1

69.8

71.0

0.86

MRA

79.1

81.4

80.3

0.84

RT-MRA

97.7

97.7

97.7

1

Am J Respir Crit Care Med 2003

treatment
Treatment
  • Respiratory support
  • Hemodynamic Support
  • Anticoagulation
contraindications
Contraindications

Relative

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 10 d postpartum

Infectious endocarditis Severe trauma within 2 mo

Pericarditis

Absolute

Active internal bleeding

indications for inferior vena caval ivc filters
Indications for inferior vena caval (IVC) filters
  • Absolute contraindication to anticoagulation (eg, active bleeding)
  • Recurrent PE despite adequate anticoagulant therapy
  • Complication of anticoagulation (eg, severe bleeding)
  • Hemodynamic or respiratory compromise that is severe enough that another PE may be lethal
embolectomy
EMBOLECTOMY 
  • Embolectomy (ie, removal of the emboli) can be performed using catheters or surgically.
  • It should be considered when a patient's presentation is severe enough to warrant thrombolysis (eg, persistent hypotension due to PE), but this approach either fails or is contraindicated.
conclusions
Conclusions
  • PE is common and under-recognized serious medical problem
  • Early diagnosis and treatment is essential for good outcome
  • High index of suspicion is needed in high risk patients