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House Officer Lecture on Pulmonary Embolism

House Officer Lecture on Pulmonary Embolism

Published in: Health & Medicine

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  • Transcript

    • 1. Pulmonary Embolism For HousestaffHeuristics, Hoopla, and Heroics Frank W Meissner, MD, RDMS FACP, FACC, 1 FCCP, FASNC, CPHIMS, CCDS
    • 2. Basic Definition MPA > Ao => PAHOcclusion of pulmonary blood vessels by embolus. 2
    • 3. Startling Facts3rd most common cause of death2nd most common of unexpecteddeath60% of pxts dying in hospital haveP.E.Diagnosis is missed 70% time 3
    • 4. Incidence/ MortalityIn U.S. 355,000 cases per year240,000 deaths per year=> crude mortality rate 240/355= 68% 4
    • 5. US AMI Deaths 959.2 1,000 750 Deaths (thousands) 544.7 500 250 93.8 32.7 0 CHD Cancer Accidents HIV/AIDSAmerican Heart Association. Heart and Stroke Statistical Update 2007. 5
    • 6. AMI per Day 5% CRUDE MORTALITY RATE 68% Vs CRUDE MORTALITY RATE PE per Day 6
    • 7. Primary Internship Heuristic Why is my cross cover patient not having an AMI, Pulmonary Embolism, or Sepsis Syndrome? If you can always explain why NOT - you will never have innocent blood on your hands. 7
    • 8. Thrombus Formation 8
    • 9. Other Embolic Phenomena Fat Embolism Air Embolism 9
    • 10. Principle Pathophysiology 10
    • 11. Virchow’s Triad Stasis Immobility - Advanced Age - Recent Surgery Pregnancy - Obesity - Chronic Lung Disease - HF - Afib Hypercoagulability Pregnancy - Malignancy - Hormonal Therapy (estrogen/OCPs) Polycythemia Vera, Thrombocytosis, AIHA, Sickle Cell Dz Factor V Leiden, Protein C&S deficiency, Factor VIII mutations Prothrombin mutations, anti-thrombin III deficiency " The physicians are the natural Chronic Lung Disease - HF - Afib attorneys of the poor, and the social problems should largely be solved by them."                Rudolph Virchow, MD Vascular Injury Recent Surgery - Varicose Veins - Thrombophlebitis Lower- Extremity Fractures - Burns 11
    • 12. ClinicalChest pain (esp pleuritic) shock, collapseTachycardia, atrial fibrillation, arrhythmia,anxietyDizziness, pre-syncope, syncopeDyspnea, tachypnea, hemoptysis, non-productive coughFindings suggesting DVT : Swelling; Pain ortenderness; Increased warmth; Red, blue, ordiscolored skin 12
    • 13. Clinical Findings Angio Proven PE Tachypnea (>20) 92%Dyspnea 84% Rales 58%Pleurisy 74% Accentuated S2 53%Anxiety 59% Tachycardia 44%Cough 53% Fever >37.8 43%Hemoptysis 30% Diaphoresis 36%Sweating 27% S3/S4 34%Nonpleuritic ChestPain 14% Thrombophlebitis 32%Syncope 13% LE Edema 24% 13
    • 14. Dos HeuristicNew Onset Atrial Fibrillation =Pulmonary Embolism until provennot to be the casePulmonary embolism MOST easilycorrected (obstructive) shock state∴ never < #2 Differential Dx Unexplained sudden shock Collapsed patient 14
    • 15. Clinical Syndromes Classic Triad (Pleuritic Chest Pain, Dyspnea, Hemoptysis) < 20% of cases 3 discrete presentations Pulmonary Infarction Submassive PE Massive PE 15
    • 16. Graphics, Labs, Images Two Classical EKG Patterns N0-4 Boards S1- Q3 RAE >2.5 mm RV T3 = p pulmonale Strain 16
    • 17. Graphics, Labs, Images Chest X-ray Findings Cardiomegaly 27% Normal Study 24% Atelectasis 23% Elevated Hemidiaphragm 20% Pleural Effusion 18% Parenchymal Pulmonary Infiltrates 17% 17
    • 18. Classical Chest X-ray Findings N0-4 Boards Westermark’s Sign Dilitation of Pulmonary Artery Proximal to embolus with collapse of distal vessels with sharp cutoff of vessel contour Hampton’s Hump Triagnular or rounded pleural-based infiltrate with the apex toward the hilum, usually located adjacent to the hilum. 18
    • 19. Pulse Ox & ABG Myths Hypoxia Most Pxts with PE will have nml oximetry and nml A-a gradient with PE A-a gradient measure of gas exchange Classical finding of PE is increased dead space ventilation 19
    • 20. Dead Space VentilationTv 500 ml, paCO2 42 mmHg, ETCO2 40 mmHgETCO2 surrogate for expired CO2 ETCO2According to Bohr Equation Normal Alveolar Dead Space is negligible in PE can become large 20
    • 21. D-DimerA Fibrin split product Multitude of False (+) causesMarker of clot lysisCirculating T1/2 approx 4-6 hrQuantitative Assay sensitivity 80-85% negative predictive value 93-100% 21
    • 22. D-Dimer Assays Qualitative Bedside RBC agglutination test Quantitative Enzyme lined immunosorbent assay (ELISA) Positive > 500 ng/ml 22
    • 23. V-Q ScanPIOPED Prospective Investigation of Pulmonary Embolism DiagnosisV-Q imaging approach in PIOPEDPreferred test for Pregnant Patient 50 mrem vs 800 mrem (Spiral CT) 23
    • 24. V/QDecision Schema High Prob Rx 4 PE Normal 20% PE rate Pre-test Prob Low (-) Rx High => angio Low Prob => angio 24
    • 25. V-Q Scan Matched Defect -=> Low Prob Mismatched Defect -=> High Prob25
    • 26. Spiral CT Scaning Advantages Quick & Commonly available Alternative Dx (“triple R/O”) DisAdvantages Cost ($600-$900/scan) Renal Fxn limits Use (Crea ≤ 1.2-1.6) Rad Dose Limited Specificity for subsegmental emboli 26
    • 27. THROMBUS L-PULMONARY ARTERY 27
    • 28. THROMBUS 2ND ORDER ARTERY 28
    • 29. THROMBUS 3RD ORDER ARTERY 29
    • 30. THROMBUS 3RD ORDER ARTERY 30
    • 31. THROMBUS 3RD ORDER ARTERY 31
    • 32. Pulmonary Angio“gold standard” TestInterluminal defect or cutoff sign‘Court of Last Resort’Less radiation and less dye than CT 32
    • 33. Echo Dx of Pulm EmbolismMore than 80% have R-heart Abnmlty Direct Viz of thrombus RV Dilatation RV hypokinesis with apical sparing Abnml intraventricular septal motion TR - acute PA Dilatation Lack of inspiratory collapse of IVC 33
    • 34. 2/3 Echo Criteria = 56% Sensitivity & 90% SpecificityRV HypokinesisRVEDD > 27 mm (withoutRV Hypertropy)TR Velocity > 2.7 m/sec 34
    • 35. Echo - D-Shaped SeptumParadoxical Septal Motion 35
    • 36. Echo - McConnell’s Sign 1. McConnell M.V., Solomon S.D., Rayan M.E., Come P.C., Goldhaber S.Z., Lee R.T. 2. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. 3. Am J Cardiol 36 1996;78(4):469-473
    • 37. Echo - Severe TR -Severe RV Systolic 37
    • 38. Echo - Elevated IVC Pressure 38
    • 39. LE UltrasoundUseful only if (+)unless pxt has symptomatic LE findings(swelling or pain) DVT Test Criteria30-40% ‘negative’ studies Criteria Sensitivity Specificity PPV NPV In Asymptomatic LE Thrombus 50% 92% 95% 37% Have MD-CT Dx’ed PE Incompressible 79% 67% 88% 50% No Spontaneous 76% 100% 100% 57% Flow Critical Care Ultrasonography: Levitov, Absent Phasic 92% 92% 97% 79% Mayo, Slonim - 2009 - pg 300/Table Flow 26.1 - McGraw Hill Medical 39
    • 40. Tables TABLE 2 Massive PETABLE 1 -Systolic arterial pressure <90 mm Hg or drop in 40Modified Wells Criteria mm Hg from baselineClinical Assessment for pulmonary embolism -Shock manifested by signs of tissue hypoperfusionClinical Symptoms of DVT (leg swelling, pain with palpation) Submassive PE3.0 -Right ventricular dysfunction or pulmonaryOther Diagnosis less likely then pulmonary embolism 3.0 hypertensionHeart rate > 100 1.5 -Hemodynamically stableImmobilization (≥ 3 days) or surgery in the previous 4 -No evidence of shockweeks 1.5Previous DVT/PE 1.5 TABLE 3Hemoptysis 1.0 Thrombolytic Therapy ContraindicationsMalignancy 1.0 AbsoluteSimplified clinical probability assessment Score History of hemorrhagic strokePE likely >4.0 Active intracranial neoplasmPE unlikely ≤4.0 Recent (<2 months) intracranial surgery or trauma Active or recent internal bleeding in prior 6 months PERC Score Applies only to low risk pxt Relative (<15%) Bleeding diathesis Age < 50 Uncontrolled severe hypertension HR < 100 -(systolic BP >200mmHG or diastolic BP > 110mmHG) If all 8 criteria O2 Sat RA >94% Surgery within the previous 10 Days are meet than No past Hx/o DVT/PE Thrombocytopenia clinical No recent trauma or surgery probability <2% No hemoptysis and CT imaging No exogenous estrogen is not necessary No clinical signs of DVT 40
    • 41. Immediately Administer 1) Unfractionated heparin (UH) 80 units/ kg/bolus Diagnostic Treatment Algorithm for Suspected or followed by 18 units/kg/hr or 2) Lovenox 1 mg/kg SQDiagnosed Submassive/Massive Pulmonary Embolism -Consider renal function -Consider need for procedures or surgery +TABLE 1 1) LE Dopplers 3) Stabilize patient and transfer to MICU/Modified Wells Criteria 2)Consider SICUTABLE 2 Pulmonary ( - ) Spiral Chest CT + angiogram or 4) Obtain EKGMassive PE repeat (PE Protocol CT)Submassive PE test in 24 *Note normal troponin I andTABLE 3 hours if clinical ( + ) pro-BNP values have been associated with low mortalityThrombolytic Therapy suspicion and anticoagulation alone may remains highContraindications Echo Echo Order Troponin I Echo & pro-BNP* Hemodynamically 1) IVC Filter Unstable 2) Consider Surgical Embolectomy Submassive PE Massive or Submassive Hemodynamically 1) Continue UH or Stable 1) TPA 100 mg over 2 hr -Consider contraindications 2) Continue Lovenox (Table 4) -Consider renal function or or 2) Catheter Embolectomy/TPA Absolute contraindication 3) TPA 100 mg over 2 hr or anticoagulation -Consider contraindications 3) Surgical Embolectomy (Table 3) and or 4) UH/LMWH after 1,2,3 4) Catheter directed and If clinical 5) Consider IVC filter embolectomy/TPA placement deterioration 41
    • 42. 42
    • 43. Interventional Techniques Pigtail Catheter - macerate fresh clot Balloon Angioplasty - rapid frag of clot - successful even with chronic clotRheolytic Catheter (Angiojet) - large volumes of saline and aspiration - arrhythmia 2ndary Adenosine release from hemolyzed RBC’sArrow-Treretola Percutaneous Thrombolytic DeviceUltrasound Fragmentation Catheter 43