A basic description of Pulmonary Embolism and treatment according to the NICE guidelines UK.

1. Princess Royal Hospital
SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
Dr AbubakkarRaheel
IMT-1Respiratory Medicine
24February2020

2. PRINCESS ROYAL HOSPITAL
SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
• Pulmonary embolism (PE) is a condition in which one or more emboli, usually arising from a
thrombus formed in the veins, are lodged in and obstruct the pulmonary arterial system, causing severe
respiratory dysfunction.
PE
Provoked Unprovoked

3. PRINCESS ROYAL HOSPITAL
SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
•Provoked PE is associated with an antecedent (within 3 months) and transient risk factor
such as significant immobility, surgery, trauma, pregnancy, concomitant DVT and the use of
the combined contraceptive pill or hormone replacement therapy. These risk factors can be
removed, thereby reducing the risk of recurrence.
•Unprovoked PE (30-50%) occurs in the absence of a transient risk factor. The person may
have no identifiable risk factor or a risk factor that is persistent and not easily correctable
(such as active cancer or thrombophilia). Because these risk factors cannot be removed, the
person is at an increased risk of recurrence.

4. PRINCESS ROYAL HOSPITAL
SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
VTE
DVT PE
Venous thromboembolism is a term used to encompass both PE and DVT

5. PRINCESS ROYAL HOSPITAL
SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
3 characteristic
presentations of PE
Massive PE Sub massive PE
Pulmonary
Infarction
shocked
<50% obstruction
Mostly stable

6. PRINCESS ROYAL HOSPITAL
SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
PREVALENCE
• 3rd most common cardiovascular disease after MI and Stroke (VTE)
• 100 - 200 per 100,000 people (VTE)
• 60 - 70 per 100,000 people (PE)
• 45,594 cases (2013-2014)
• 28,000 hospital admissions (2011)
• 2300 deaths from PE (2013)
• One of the main direct cause of maternal death (UK)
• Approx 25,000 people per year die from preventable VTE (UK)

7. PRINCESS ROYAL HOSPITAL
SHREWSBURY AND TELFORD HOSPITALS NHS TRUST

8. PRINCESS ROYAL HOSPITAL
SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
PATHOPHYSIOLOGY
Hypoxemia
Alveolar collapse
Reduced cardiac output
Elevation of pulmonary artery pressure
Intrapulmonary dead space + impaired gaseous exchange
pulmonary artery obstruction
Thrombus dislodged

9. PRINCESS ROYAL HOSPITAL
SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
Risk
stratification
(Revised) GENEVA score
Age >65 (+1)
• Previous DVT/PE (+3)
• Surgery (GA)/lower limb fracture
(+2)
• Active malignancy (+2)
• Unilateral lower limb pain (+3)
• Hemoptysis (+2)
• Tachycardia (0/+3/+5)
• Pain on LL palpation and
edema.(+4)
Risk Factors – (Revised) Geneva and Wells Score for PE
WELLS criteria
Clinical features of DVT (+3)
Tachycardia 100+ (+1.5)
Immobilization/surgery (+1.5)
Previous DVT/PE (+1.5)
Hemoptysis (+1)
Chemotherapy/Ca (+1)
Alternative diagnosis less likely
than PE (+3)

10. PRINCESS ROYAL HOSPITAL
SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
Symptoms
• Dysnea
• Tachypnea
• Pleuritic chest pain
• Features of DVT
• Retrosternal chest pain
• Cough +/- hemoptysis
• Dizziness
• Syncope

11. PRINCESS ROYAL HOSPITAL
SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
Signs
• Tachycardia
• Hypoxia
• Pyrexia
• Elevated JVP
• Gallop rhythm, widely split 2nd HS, TR murmur
• hypotension
• Cardiogenic shock

12. PRINCESS ROYAL HOSPITAL
SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
Investigations
• Routine bloods
• Cardiac Troponin
• ABG
• D dimer [qualitative (bedside) vs quantitative (ELISA) assays]
• Chest x ray
• ECG
• Imaging
a) CTPA
b) V/Q scanning
c) Echo
d) Lower limb compression venous ultrasound

13. PRINCESS ROYAL HOSPITAL
SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
Chest x ray
Classical peripheral wedge
shadow of pulmonary infarction
(RCEM learning)

14. PRINCESS ROYAL HOSPITAL
SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
ECG
S1QIII TIII pattern (10% only)

15. PRINCESS ROYAL HOSPITAL
SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
CTPA
Massive filling defect in
main pulmonary vessels
(RCEM)

16. Management – Primary Care setting
Wells score
d-dimer
CTPA/LMWH
Other
diagnosis
CTPA/LMWH
<4
>4
positive negative
PRINCESS ROYAL HOSPITAL
SHREWSBURY AND TELFORD HOSPITALS NHS TRUST

17. PRINCESS ROYAL HOSPITAL
SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
Management – Clinical setting
• Oxygen (Target sats 94% above)
• Anticoagulant – 3 months (followed by re-assessment of risks and benefits)
• Sub-massive without RV strain: LMWH/Fondaparinux followed by NOAC (Apixaban,
Rivaroxaban, Dabigatran, Edoxaban)
• Sub-massive with RV strain: LMWH followed by alteplase 100mg over 2 hrs IV
• Cardiovascular compromise: LMWH followed by thrombolysis (if no contraindications to
fibrinolysis)
• Active ca and pregnancy: LMWH rather than warfarin
• Thrombolysis (alteplase 50mg IV bolus)

18. In-Hospital Management
Confirmed
PE
Pharmacological
LMWH Fondaparinux
Unfractioned
Heparin
Oral
Anticoagulant
Mechanical
IVC Filter Thrombectomy
PRINCESS ROYAL HOSPITAL
SHREWSBURY AND TELFORD HOSPITALS NHS TRUST

19. PRINCESS ROYAL HOSPITAL
SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
References
• National Institute for health and care excellence www.nice.org.uk
• British Lung Foundation (2019) Pulmonary embolism statistics. British Lung Foundation
• NF (2018) British National Formulary. 76th edn. London: British Medical Association and
Royal Pharmaceutical Society.
• BTS (2018) BTS Guidelines for the outpatient management of pulmonary embolism. British
Thoracic Society.
• Royal College of Emergency Medicine. Rcemlearning.co.uk

20. PRINCESS ROYAL HOSPITAL
SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
Questions