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Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
Management of pulmonary embolism in emergency department
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Management of pulmonary embolism in emergency department

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An short overview of the diagnostic approach and treatment options for Pulmonary Embolism which is a Medical Emergency. In the USA alone about 600,000 people are diagnosed with Pulmonary Embolism …

An short overview of the diagnostic approach and treatment options for Pulmonary Embolism which is a Medical Emergency. In the USA alone about 600,000 people are diagnosed with Pulmonary Embolism every year. However, this is just the tip of the iceberg as many more people have sudden head due to this notorious condition. This Power Point presentation will give you some idea based on my experience in the Emergency Departments in 3 continents of the world.

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  • 1. Management of Pulmonary Embolism in Emergency Department Dr A. Barai MBBS, MRCS Ed, MSc Registrar in Emergency Medicine
  • 2. Topics • Introduction • Diagnostic approach • Treatment options • Special circumstances: Pregnant patient • Prevention
  • 3. Introduction • Pulmonary embolism (PE) is a medical emergency where pulmonary artery or its branches are blocked with embolic substances most commonly blood clots • Most cases are not life threatening. • Incidence: 600,000/year in USA • Mortality rate: 50,000 to 200,000/yr in US
  • 4. Types of PE • Massive PE: Acute PE with obstructive shock or SBP <90 mmHg • Sub-massive PE: Acute PE without systemic hypotension (SBP ≥90 mm Hg) but with either RV dysfunction or myocardial necrosis • Non-massive or low risk PE: None of the above severe features.
  • 5. Pathophysiology Deep vein thrombosis from large vein commonly above the knee → Inferior vena cava → Right atrium → Right ventricle → Pulmonary artery → PE Ventilation perfusion mismatch → Hypoxemia ↓Venous return → Right heart failure → Shock
  • 6. Diagnosis • Risk stratification • Clinical examination • Bed side tests • Laboratory tests • Imaging techniques
  • 7. Risk factors • Alteration of blood flow: – Prolonged immobilisation, – Obesity, – Pregnancy, – Cancer • Factors in blood vessel wall: – Surgery, – Catheterisation. – Trauma • Hypercoagulable states: – Estrogen containing OCP, – Genetic thrombophilia (Factor V Leiden deficiency, Protein C and Protein S deficiency, antithrombin deficiency etc.), – Acquired thrombophilia (antiphospholipid syndrome, nephrotic syndrome, paroxysmal nocturnal hemoglobinuria)
  • 8. Risk stratification • Clinical judgement • Wells score for PE • Modified Geneva score for PE
  • 9. Wells score for PE
  • 10. Modified Geneva score for PE
  • 11. Clinical Presentation: Symptoms • Chest pain: Sharp, pleuritic in nature, no radiation, aggravated by coughing and deep breath • Haemoptysis • Shortness of breath • Collapse • Palpitations
  • 12. Clinical Presentation: Signs • Dyspnoea, cyanosis, pale • Tachypnea • Tachycardia • Hypoxia • Hypotension • Pulmonary hypertension
  • 13. Chest examination • May be normal • Friction rub • Features of pleural effusion • Raised JVP
  • 14. Investigations • Bed side tests: ECG, ABG • Blood tests: D-dimer, FBC, Troponin, UEC • Imaging techniques: Ultrasound/ Doppler scan, Chest xray, CTPA, V/Q scan, Echocardiogram
  • 15. ABG findings in PE • pH= ↑ • PaO2= ↓ • PaCO2= ↓ • HCO3= Normal • Aa gradient= Large Aa gradient= PAO2- PaO2
  • 16. Chest xray • Mostly normal findings • Done to exclude other pathology • Plural effusion • Specific signs: - Hampton’s hump - Westermark sign
  • 17. Hampton’s hump
  • 18. Westermark sign
  • 19. ECG findings in PE • Normal sinus rhythm • Sinus tachycardia • Tall peaked T waves in V1- V4 • S1Q3T3 pattern: Not specific. Can be seen in any Cor pulmonale syndrome • RBBB
  • 20. S1Q3T3 pattern ECG
  • 21. D-dimer in PE • D-dimer is a type of Fibrin degradation product • Can be raised due to a number of reasons • Negative D-dimer rules out PE/DVT in 98% cases • False positive D-dimer: infection, pregnancy, renal failure, post-operative
  • 22. Echocardiogram in PE
  • 23. CTPA Indications: - Suspected PE Contra-indications: - Renal failure - Pregnancy - Allergy to radio-contrast Procedure: - Radioactive iodine administered IV - CT scan performed
  • 24. Ventilation-perfusion scan Indications: - Renal failure - Pregnancy Procedure: - Ventilation scan with Xenon inhalation - Perfusion scan with Tc99m labelled radioactive dye infusion - Scan V/Q - Result: unmatched V/Q
  • 25. Pulmonary angiogram • Gold standard test for PE • Not practised due to the side effects and high mortality • Procedure: – Catheter inserted to right ventricle – Radio opaque dye injected – Imaging technique used to identify the clot
  • 26. Treatment options • Symptomatic treatment: – ABCD approach – Oxygen – Analgesia • Anticoagulation: – IV Heparin – S/C LMWH eg Enoxaparine, Dalteparine – Oral Warfarin • IVC filter: If there is contra-indications for anti-coagulation • Thrombolysis: tPA eg Alteplase, Tenectaplase • Surgical procedures: Pulmonary embolectomy
  • 27. Treatment options • Massive PE: Thrombolysis/embolectomy • Sub-massive PE: Strongly consider thrombolysis/embolectomy but need to balance risk of bleeding • Non-massive PE: Anticoagulation
  • 28. Thrombolysis • Indications: – Massive PE – Sub-massive PE where risk of bleeding low • Contraindications: – Bleeding, recent stroke, HI, current GI bleeding, bleeding PUD, surgery within 7 day, prolonged CPR • Drugs: – Alteplase 100mg IV: 15mg IV stat followed by 85mg over 2 hours – Followed by Heparin infusion
  • 29. Anticoagulation • IV Heparin: – 80 units/kg bolus followed by – 18 units/kg infusion • Monitor APTT 60-90 sec • Side effects: – HITS (Heparin induced thrombocytopenia syndrome): paradoxical hypercoagulable state leads to clots – Bleeding
  • 30. Anticoagulation Low molecular weight Heparin (LMWH) Enoxaprin (Clexane): S/C - 1.5mg/kg/24 hours Or 1mg/kg/12 hours - 1 mg/kg/24 hours in renal impairment Duration: 6 to 9 months Side effect: Low HITS
  • 31. Anticoagulation • Vitamin K antagonist • Warfarin: – 5mg PO initial dose – Check regular INR 2-3 • Side effects: – Bleeding – Unusual bruises – Headache
  • 32. IVC filter Indications: - DVT with massive pulmonary embolus - Recurrent PE not treatable with anticoagulation - Absolute contra-indications for anti-coagulation - Trauma patients
  • 33. PE in Pregnancy • All three components of Virchow’s triad are affected during pregnancy • D-dimer has high negative predictive value. False positive result is common • V/Q scan is preferred technique • CTPA can be done if VQ is inconclusive • Preferred treatment option: LMWH • Warfarin is contraindicated
  • 34. Prevention of PE • Control of obesity • Stop smoking • Stockings • Heparin: 5000 units/day IV • Enoxaprin: 40 mg/day S/C
  • 35. And finally… PE is often over-diagnosed; PE is often under-diagnosed; The over- or under-diagnosis of PE results in increased cost, morbidity, mortality and medico-legal risks.
  • 36. References • Agnelli G, Becattini C. Acute pulmonary embolism. N Engl J Med. 2010 Jul 15;363(3):266-74. doi: 10.1056/NEJMra0907731. Epub 2010 Jun 30 • Bourjeily G, Paidas M, Khalil H, et al. Pulmonary embolism in pregnancy. Lancet. 2010;375:500-512 • Hofman, M. S.; Beauregard, J. -M.; Barber, T. W. et al.(2011). 68Ga PET/CT Ventilation- Perfusion Imaging for Pulmonary Embolism: A Pilot Study with Comparison to Conventional Scintigraphy. Journal of Nuclear Medicine 52 (10): 1513–1519. • Jaff MR, et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011 Apr 26;123(16):1788-830. doi: 10.1161/CIR.0b013e318214914f. Epub 2011 Mar 21. Erratum in: Circulation. 2012 Mar 20;125(11):e495. Circulation. 2012 Aug 14;126(7):e104. • Mattu, A. PE in pregnancy: A complicated diagnosis. Medscape. August 9, 2010 (Online) URL: http://www.medscape.com/viewarticle/726318 • Pulmonary embolism. Life in the fast lane. (Online). http://lifeinthefastlane.com/education/ccc/pulmonary-embolism/
  • 37. Thank you! drbarai@gmail.com

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