Pulmonary emoblism by dr yaser

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Dr Yaser Mufti
resident Faisalabad institute of Cardiology
faisalabad, pakistan

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Pulmonary emoblism by dr yaser

  1. 1.  Case presentation Dr. Yaser Mufti MD Cardiology Trainee 1/17/18/2012
  2. 2. CASE STUDY  A 25 years old young female presented to emergency complaining of Severe shortness of breath that began abruptly when went for toilet.  Associated symptoms included diaphoresis, palpitation  One weak back, prior to this event, Patient had NVD at Home. After 3 days of NVD she has mild SOB, unnoticed.7/18/2012 2/66
  3. 3. Past history She has no significant past medical history except NVD at home wk back Treatment history No specific medication usage history Family history No family history could be elicited regarding DVT or phelbitits Personal history No history of any addiction /drug allergy7/18/2012 3
  4. 4. General examination  Her BP at was 80/60mmHg , temp N  HR 147 BPM  RR 40 PM ,oxygen saturation of 90 %  She was pale , diaphoretic, and unable to speak full sentence  Her JVP was not recorded7/18/2012 4
  5. 5. Systemic examination  Cardiac exam shows tachy cardia, a fixed wide split of the second heart sound  Pulmonary exam non specific, NBVB  Abd: soft, no liver or spleen palpable  Her extremities were cold with Weak peripheral pulses.  Rest of examination normal7/18/2012 5
  6. 6. Differential Diagnosis  Pulmonary Embolism  Congestive heart failure Post Partum Cardiomyopathy  Myocarditis  ATN due to PPH7/18/2012 6
  7. 7.  sinus tachycardia at a rate of 147 BPM,ECG  Right Axis deviation 90+  ST , T wave changes7/18/2012 7
  8. 8.  Her ABG’s Ph: 7.2, PCO: 30 , PO2 : 171 , K : 3.3 , BE: -13  Her CBC , Hb 8.9 g/dl, ESR , 56mm/hr, TLC 10200, and platelet count 208000, other is in normal range  D dimer report is send but not collected7/18/2012 8
  9. 9. 7/18/2012 9
  10. 10. Echo Findings  Emergency Short Echo: (images not available)  Dilated RV(49 MM) with moderately severe Systolic dysfunction with good kinesis at RV apex  Normal LV function  TR ++, TVPG 14mmHg  Normal Mitral and AV.  IAS appears intact7/18/2012 10
  11. 11. Management  Oxygen  Heparin 5000 iu bolus iv, 1000 iu /hr  Inotropic suppor (Dobutamine/Dopamine)  Plan. Ct angio /V/Q scan / Lityic therarpy/ Doppler  Outcomes Unluckily she couldn’t survive and died after few hours of admissions7/18/2012 11
  12. 12. Short comings and Analysis •We don’t have above mentioned tests availabilities to make confirm diagnosis •Can we use Lytic therapy in this patient, without confirming PE is debatable. • She should be managed in Full ICU facilities, rather to mange in only emergency ward.7/18/2012 12
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  15. 15. Virchow triad  Intimal vessel injury  Stasis  hypercoagulability7/18/2012 15
  16. 16. PE: A Clinical Challenge  Common: 250,000 cases/year  Mimics many other illnesses  Potentially fatal (15%)  Treatment potentially dangerous  No single reliable diagnostic test  Under- and over-diagnosed7/18/2012 16
  17. 17. Acquired Risk Factors Advancing age Arterial disease, including carotid and coronary disease Personal or family history of VTE Recent surgery, trauma, or immobility, including stroke CCF/COPD Acute infection Long- air travel Pregnancy, OCP, HRT Pacemaker, implantable cardiac defibrillator leads, or indwelling central venous catheter thromboembolism Obesity, Metabolic syndrome Cigarette smoking Hypertension, Abnormal lipid profile7/18/2012 17
  18. 18. INHERITED RISK FACTORS  Hypercoagulable states Factor V Leiden resulting in activated protein C resistance  Prothrombin gene mutation 20210  Antithrombin III deficiency  Protein C deficiency  Protein S deficiency  Antiphospholipid antibody syndrome(Acquired)  Hyperhomocystenimia7/18/2012 18
  19. 19.  Pathyphysiology7/18/2012 19
  20. 20. Clinical Classification of PE  Massive PE Systolic BP< 90 mmHg,or  Thrombolysis poor tissue Perfusion Or  Or embolectomy Mulitsystem organ failure  Or IVC filter Plus, Rt.or Lt main  Plus anticoagulant Pulmonary Art. Thrombus or high clot burden Hemodyn. Stable,but mod.  Addition of Thrombolysis  Submassive PE To severe RV dysfunction  Emblectomy or filters or enlargement remiain controversial  Small to moderate PE Normal hemodyn  Anticoagulation And normal RV Size and function7/18/2012 20
  21. 21. Pulmonary Infarction  Often characterized by pleuritic chest pain and hemoptysis  The embolus usually lodges in the peripheral pulmonary arterial tree, near the pleura.  Tissue infarction usually occurs 3 to 7 days after embolism.  Sysmptom often includes fever, leukocytosis, elevated erythrocyte sedimentation rate, and radiologic evidence of infarction.7/18/2012 21
  22. 22. Nonthrombotic PE They include fat, tumor, air, and amniotic fluid Fat embolism ,Usually after bone fractures. Air embolus during CV catheter central venous catheter. Amniotic fluid embolism , is characterized by respiratory failure, cardiogenic shock, and DIC IVDU sometimes self-inject hair, talc, and cotton that contaminate the drug they have acquired. These patients also have susceptibility to septic PE, which can cause endocarditis of the TV or PV.7/18/2012 22
  23. 23. Clinical Presentation The PIOPED study reported the following incidence of common symptoms of pulmonary embolism[30] : • Dyspnea (73%) • Pleuritic chest pain (66%) • Cough (37%) • Hemoptysis (13%) Symptoms7/18/2012 23
  24. 24. Clinical Signs• Tachypnea (respiratory rate >16/min) - 96%• Rales - 58%• Accentuated second heart sound - 53%• Tachycardia (heart rate >100/min) - 44%• Fever (temperature >37.8°C) - 43%• Diaphoresis - 36%• S3 or S4 gallop - 34%• Clinical signs and symptoms suggesting thrombophlebitis - 32%• Lower extremity edema - 24%• Cardiac murmur - 23%• Cyanosis - 19%7/18/2012 24
  25. 25. Differential Diagnosis of Pulmonary Embolism  Anxiety, pleurisy, costochondritis  Pneumonia, bronchitis  Myocardial infarction  Pericarditis  Congestive heart failure  Idiopathic pulmonary hypertension7/18/2012 25
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  27. 27. INVESTIGATIONS WELL’s SCORING /GENEVA SCORING •CBC, •ABG’S, •D-DIMER •TROPONIN •ECG •BNP •CHEST RADIOGRAPH •ECHOCARDIOGRAPHY •V/Q SCANNING •CT ANGIOGRAPHY7/18/2012 27
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  29. 29. Clinical probability of Risk A  Determine probability of PE  Low  Moderate  High  Overall clinical impression  Models/scoring systems7/18/2012 29
  30. 30. 7/18/2012 30
  31. 31. Blood tests  Troponin levels Correlation with ECG and Echo Increase mortality if positive with Acute P.E  BNP In Absence of Renal function Marker of RV dystfunction , Predictor of adverse outcome7/18/2012 31
  32. 32. ABG;s  PE significant Hypoxemia  PIOPED, only 26 % of proven PE had Pao>80mmhg  Therefore normal PaO2 can not rule out PE  However Hypoxia in absence of cardiopulmonary disease should raise suspicion of PE7/18/2012 32
  33. 33. D-Dimers It is a fibrin degradation fragment Occurs Through fibrinolysis Valuable screening test  High sensitivity; low specificity  Helpful only if Negative  Strong Negative Predictive Value-- Rules out PE when low probability  Safe, noninvasive  Rapid, inexpensive7/18/2012 33
  34. 34. Electrocardiographic Signs of PE  Sinus tachycardia  Incomplete or complete right bundle branch block  Right-axis deviation  S wave >1.5 mm in I and aVL  T wave inversions in leads III and aVF or in leads V1-V4  S wave in lead I and a Q wave and T wave inversion in lead III (S1Q3T3)  QRS axis greater than 90 degrees or an indeterminate axis  Atrial fibrillation or atrial flutter7/18/2012 34
  35. 35. Chest Radiography Useful to R/o other causes Non specific findings; pleural Effusion, atelectasis, consolidation Classic sign Focal oligemia (Westermark sign) indicates massive central embolic occlusion. A peripheral wedge-shaped density above the diaphragm (Hampton hump) usually indicates pulmonary infarction. Subtle abnormalities suggestive of PE include enlargement of the descending right pulmonary artery.7/18/2012 35
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  37. 37. V/Q Lung Scan  2nd line investigation method  Beneficial if having normal xray  Who are dye allergic in CT  Renal failure  Pregnancy  Normal V/Q Sensitivity 99%  Rules out PE  High Prob V/Q Specificity 96%  Rules in PE  But, >60% nondiagnostic  Takes >2 hr to perform  Not available at all times7/18/2012 37
  38. 38. Ultrasound and PE  US +DVT in 30-50% with PE  Positive US—confirms PE  Negative ultrasound  PE less likely, but not excluded  Sequential ultrasound  Persistently negative ultrasound at 1-2 wks <2% DVT/PE at 6mos Hull et al. J. Thromb 1996; 3:5-8.7/18/2012 38
  39. 39. Echocardiographic Signs of P.E Right ventricular enlargement or hypokinesis, especially free wall hypokinesis, with sparing of the apex (the McConnell sign) Interventricular septal flattening and paradoxical motion toward the left ventricle, resulting in a D-shaped left ventricle in cross section Tricuspid regurgitation Pulmonary hypertension with a tricuspid regurgitant jet velocity >2.6 m/sec Loss of respiratory-phasic collapse of the inferior vena cava with inspiration Direct visualization of thrombus (more likely with transesophageal echocardiography) 7/18/2012 39
  40. 40. CT Angiogram  Benefits  Limitations  Available  IV contrast  Direct image  Expensive  Alternative Dx  Patient  Pelvic/leg veins cooperation  Uncertain sens/spec7/18/2012 40
  41. 41. CT Angiogram  “CT should not be used alone for suspected PE, but combining tests improves accuracy and reduces need for angiography” ”7/18/2012 41
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  44. 44. Pulmonary Angiography Gold standard but these days not in practice due to availability of CT7/18/2012 44
  45. 45. MRI/MRA  No radiation or contrast exposure  Expensive  Not uniformly available  Limited data  Role not established7/18/2012 45
  46. 46. Hypercoagulable states7/18/2012 46
  47. 47. Thrombophilia evaluation Why test for hypercoagulability?  May affect intensity/duration of treatment  Family counseling about risks  Identify need for prophylaxis in higher risk situations7/18/2012 47
  48. 48. Thrombophilia evaluation Tests performed acutely  Leiden Factor V (APC resistance)  Prothrombin G20210A mutation  Increased homocysteine  Anti-cardiolipin antibodies7/18/2012 48
  49. 49. Thrombophilia evaluation Consider testing later  Lupus anticoagulant  Decreased Proteins C & S  Decreased Anti-thrombin III  Increased Factor VIII7/18/2012 49
  50. 50. Summary  Have index of suspicion for PE  Develop clinical probability  Interpret all tests in context of pre-test probability  Selectively for thrombophilia  Choose therapy based on clinical status7/18/2012 50
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  53. 53. Pulmonary Embolism TREATMENT OF SYMPTOMS:  Bedrest  Analgesics  Supplemental O2 Therapy7/18/2012 53
  54. 54. MEDICAL MANAGEMENT:  Anticoagulant Therapy  Thrombolytic Therapy  Surgical Embolectomy7/18/2012 54
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  56. 56. Duration of anticoagulation  Identified precipitant 3 mos  First idiopathic episode 6 mos  Prolonged/indefinite:  2 thrombotic episodes  1 spont. life-threatening episode  Anti-phospholipid antibody syndrome, ATIII deficiency7/18/2012 56
  57. 57. Un fractionated Heparin  Continue 4-5d and therapeutic on Warfarin for 2d (INR>2.0)7/18/2012 57
  58. 58. Thrombolysis  Massive PE  Acute pulmonary hypertension  RV dysfunction  Systemic hypotension  All age groups benefit  Addition to Heparin therapy  Various agents appear equivalent7/18/2012 58
  59. 59. 7/18/2012 59
  60. 60. Thrombectomy  Surgical or transvenous (catheter)  When thrombolytic unsuccessful or contraindicated, or  Massive PE7/18/2012 60
  61. 61. Vena Cava Filters  Indications:  Contraindication to anticoagulation  Recurrent PE on anticoagulation  Complications from anticoagulation  Massive PE with poor reserve  Problems with filter thrombosis7/18/2012 61
  62. 62. Predictors of Increased Mortality  Hemodynamic instability  Right ventricular hypokinesis on echocardiogram  Right ventricular enlargement on echocardiogram or chest CT scan  Right ventricular strain on electrocardiogram  Elevated cardiac biomarkers7/18/2012 62
  63. 63. Take home message Pe common but overlook High suspicion to make diagnosis ABG, d-dimer, CT imp diagnostic tools Prevention is much more important than treatment Take home message: for DVT Diagnosis Combine clinical probability, d-dimer, and ultrasonography Take home message: for PE diagnosis Combine clinical score, d-dimer, and CT pulmonary angiography7/18/2012 63
  64. 64. 7/18/2012 64

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