medical surgical emergency cases

1. PULMONARY EMBOLISM
Nita karki
NPCC 2nd year

2. Introduction
• A pulmonary embolism (PE) occurs when
thrombus or emboli lodges in the pulmonary
arterial system, disrupting the blood flow to a
region of the lungs.
• Thrombotic : deep leg veins, right ventricle, the
upper extremities, and the pelvic veins.
• Non-thrombotic emboli : fat, tumors, amniotic
fluid, air, and foreign bodies.

3. Epidemiology
• Majority of patients in the ICU have one or more
risk factors for PE. Incidence varies from 5-33%.
• 50% of patients with proximal lower limb DVT and
20 % with upper limb DVT have asymptomatic PE at
presentation.
• PE was diagnosed during life and confirmed at
autopsy in 20 % cases. Overall, the incidence of DVT
in ICU patient not receiving prophylaxis is 30% with
a 15% incidence of PE, of which 5% may be fatal.

4. Definition
• Pulmonary embolism is the blockage of
pulmonary arteries by thrombus, fat or air
emboli.

5. Risk Factors
• Prior venous thromboembolism
• Orthopedic procedure
• No prophylaxis- SCD, anticoagulant
• Abdominal/pelvic surgery
• Malignancy
• Obesity
• Female > 30 yrs + OCPs+ smoker
• Spinal cord injury
• Heparin iduced thrombocytopenia
• Hypercoaguable state ( protein deficiencies)
• Congestive heart failure
• Indwelling central venous catheter
• Pregnancy

6. Pathophysiology
• Increased Dead Space
• Bronchoconstriction
• Compensatory Shunting
• Hemodynamic Consequences

7. Pathophysiology

8. Classification
• Non massive
• Sub massive
• massive

9. Assessment and diagnosis
The patient with a PE may have any number of
presenting signs and symptoms, with the most common
being
• tachycardia and tachypnea.
• Hemoptysis,
• dyspnea,
• increased pulmonic component of the second heart
sound (P1),

10. Diagnostic investigations
• Chest x-ray:
▫ cardiomegaly
▫ pleural effusion,
▫ elevated hemidiaphragm,
▫ enlargement of the right descending pulmonary
artery (Palla’s sign),
▫ a wedge-shaped density above the diaphragm
(Hampton’s hump), and
▫ the presence of atelectasis.

13. Cont…
• ECG: Sinus tachycardia
• ECHO: transthoracic/transesophageal, for
visualization of emboli.
• Peripheral vascular studies
• ABGs: hypoxemia, hypocarbia, high pH
• D-dimer
• Ventilation perfusion scan
• Pulmonary angiography

15. PECT

18. The revised Geneva score
score
Older than 65 years 1
Previous DVT or PE 3
Surgery or fracture within 1 month 2
Active malignant condition 2
Unilateral lower limb pain 3
Hemoptysis 2
Heart rate
75-94 beats/min
95 beats or more
3
5
Pain in lower limb deep venous
palpation and unilateral edema
4
The probability is assessed as follows
• Low probability (0-3 points)
• Intermediate probability (4-10 points)
• High probability (≥11 points)

19. Differential diagnosis

20. Treatment
• Anticoagulation therapy:
▫ UFH- 5,000U SC every 12 hourly, then 1000U/hr
IV infusion
▫ LMWH- enoxaparin 40 mg SC daily or dalteparin
2,500U SC daily
▫ warfarin- 2.5-7.5 mg/day orally
• Thrombolytic therapy: urokinase, streptokinase,
alteplase, reteplase
• Surgical intervention: pulmonary embolectomy

21. Thrombolytic therapy regimens
Drug Protocol
Streptokinase 250,000U IV (loading dose
during 30 min, then 100,000
U/h for 24 h)
Urokinase 2,000 U/Ib IV (loading dose
during 10 min, then 2,000
U/Ib/h for 12-24 h)
Tissue-type plasminogen
activactor
100mg IV over 2h or 0.6 mg/kg
over 15 min

22. INFERIOR VENA CAVA FILTERS
The two principal indications for insertion of an
IVC filter are
• active bleeding that
precludes anticoagulation
and
• recurrent venous
thrombosis despite
intensive anticoagulation.

24. Collaborative management

25. Diagnostic Evaluation for Suspected Acute Pulmonary
Embolism (PE) in the Intensive Care Unit (ICU)

26. Cont…

27. Treatment of Confirmed Acute PE in the
ICU

28. Cont…

29. Risk of treatment
• Bleeding
• Heparin-Induced Thrombocytopenia

30. Contraindication for thrombolytic
therapy
Absolute contraindication
• Prior intra cranial hemorrhage
• Known structural cerebral vascular lesion
• Known malignant intra cranial neoplasm
• Ischemic stroke within 3 month
• Suspected aortic dissection
• Active bleeding or diathesis

31. Cont…
Relative contraindication
• History of chronic poorly controlled HTN
• Traumatic or prolonged CPR or major surgery
less than 3 weeks
• Recent internal bleeding
• Non-compressible vascular puncture
• Pregnancy
• Active peptic ulcer
• Current use of anticoagulant : INR>1.7 PT>15s

32. Reference
• Harrison’s principles of Internal Medicine 20th
Edition
• Marin Kollef.The Washington Manual of Critical
Care.
• Urden Linda D., Stacy Kathleen M., Lough Mary
E. Critical Care Nursing. Diagnosis and
Management.
• Twigg et al intensive care medicine 2001.
• Cook et al J critical care med 2000.