Incidence, clinical detection, investigation & treatment

1. By:

2. These items will be discussed:
• 1- Incidence
• 2- Sources of emboli
• 3- Clinical presentation
• 4- Investigations
• 5- Treatment

3. 1- Incidence
• Statistics about the incidence of pulmonary in
Egypt is Widely variable and unreliable but
DVT & PE are common post operative
complications
• 2-3 % of all hospital mortalities are due to PE

4. 2- Sources of emboli
• DVT (most common)
• Infective endocarditis and thrombi of the Rt
side of the heart
• Fat embolism ( Bone fracture)
• Amniotic Fluid Embolism
• Air Embolism

5. DVT & Detached Thromboembolus

6. 3- Clinical Picture:
• According to the size of Embolism
1- Small sized emboli
(impacted in peripheral arterioles)
2- Medium sized emboli
(impacted in branches of pulmonary a.)
3- Large sized emboli
(in main Pulmonary a. or one of its branches)

7. 1- Small sized emboli
• Usually asymptomatic but cough, dyspnea or
chest discomfort may occur.
• Recurrent small emboli with obliteration of
more than 65% of pulmonary vascular bed
leads to thromboembolic pulmonary
hypertension that leads RV++ & RHF
( subacute corpulmonale)

8. 2- Medium sized emboli
• Leads to pulmonary infarction
• CO
- cough - Haemoptysis
- Pleuritic chest pain - Dyspnea
- Fever
• OE
- Pleural rub
- Crepitations over the involved area (may be)

9. 3- Massive pulmonary embolism
• Severe precordial pain & chest tightness
• Marked dyspnea
• Cyanosis (hypoxia), Tachypnea, Tachycardia
• Acute Rt sided HF & SHOCK

10. 4- Investigations
• LAB. :
1- ABG: Hypoxia
2- Inc. TLC, ESR, LDH
3- Plasma D-dimer

12. • ECG:

13. • X – Ray:
Radiology

14. • Usually there is no significant finding but normal chest
x-ray with hypoxia in hospitalized patient suspect PE

15. • Spiral CT:

17. • Lung scan (Ventilation Perfusion scan “V|Q scan”)

18. • Pulmonary Angiography:
- It’s gold standard for diagnosis but it’s highly invasive

19. 5- Treatment
• Prophylaxis & TTT of DVT is very important in
prevention of PE:
• Prophylaxis:
1- Early mobilization after surgeries
2- Exercises of the leg in bed
3- Elastic stocks
4- Adequate hydration postoperative
5- Anticoagulant in high risk patients
( low dose heparin 5000 IU S.C 2 hrs before operation &
every 12 hrs post. Till the pt. is ambulant.
OR LMWH at the night of the operation & 12 hrs post.)

21. • 2- Oral anticoagulant (Warfarin)
- Heparin is discontinuated after 3 days
of overlap TTT.
- needs follow up by INR (PT)
- Given for 3-6 months & if liable for
rethrombosis warfarin is given for life

22. TTT of massive PE
• Resuscitation:
1- Oxygen therapy
2- Analgesics >>> Pethidine
3- Dobutamine may improve RV function
4- CPR if arrest

23. • Thrombolytic therapy:
- Cardiac catheter is inserted into the pulmonary
artery & 600000 units of Streptokinase are injected
followed by 100000 unitshr for 72 hrs.
• Catheter Suction Embolectomy:
Via the IJV or CFV by local anaesthesia & under image.
• Urgent open pulmonary embolectomy:

24. TTT of mild to moderate PE
• Anticoagulant therapy:
as DVT
• For recurrent small emboli that cause
pulmonary HTN:
Greenfield Caval Filter