PE Secondary to Trauma

1. ARF SECONDARY TO PE
Dr. SINGH , RABINDRA

2. GENERAL DATA

3. • Name: D.J.C
• Age: 61
• Gender: male
• Status: married
• Religion : Roman Catholic
• Address : Langcuas San Fernando LA union

4. HISTORY OF PRESENT ILLNESS
• One hour prior to admission, while driving along the high way the patient Had a
collision course with another motorcycle in Langcuas San Fernando LA union,
at around 11am on January 27,2018.there was no loss of consciousness, and
vomiting noted. Patient was then rush to LORMA ER and was subsequently
admitted.

5. PAST MEDICAL HISTORY
• Past medical history: unremarkable
• Family history : unremarkable
• Personal/social history: alcoholic beverage drinker

6. REVIEW OF SYSTEMS
• Unremarkable

7. PHYSICAL EXAMINATION
• General survey: conscious, coherent, and in distress
• Vital signs: bp: 140/80, HR: 111, RR: 19, temp: 36.5
• Skin: warm to touch, no pallor, no cyanosis, no jaundice,
• Head and neck: anicteric sclera, pink palpebral conjunctiva, no nasoaural
discharge, no sinus tenderness, moist lips and oral mucosal, no CLAD, no tp
wall congestion
• Thorax: heart: normal rate, regular rhythm, PMI at 5th ICL MCL, no heaves, no
thrills, no mmurmus. Chest and lungs: symmetrical chest wall expansion, no
retraction, no lagging, no crackles, no wheezes.

8. • Abdomen: flabby, soft, non distended, normooactive bowel sounds, no
abdominal aortic bruins, tympanitic, non tender on all quadrants.
• Extremities : (+) multiple abrasions right leg, (+) closed fracture right leg
• Lymph nodes: no cervical lymphadenopathies
• Genitalia: n/a
• Rectal: n/a

9. • Neuro exam: GCS15(E4V5M6)
• Alert oriented to 3 spheres, (-) dysarthria, (-) aphasia
• CN I: able to smell
• CN II: no visual field defects
• CN III, IV, VI: pupils equally reactive to light, intact EOM, no preferential gaze
• CN V: (+) corneal reflex (+) sensation over the face
• CN VII: (-) facial assymetry , (+) intact muscle of facial expression

10. • CN VIII: able to hear sound
• CN IX, X: (+) gag reflex
• CN XI: moves head side to side against resistance
• CN XII: tongue at midline
• Motor: 5/5 right upper extremity, 0/5 right lower extremity (fracture right leg)
5/5 left upper extremity, 5/5 left lower extremity
• Sensory: 100% on all extremity
• No signs of meningeal irritation (-) Kernig sign, (-) brudinzky sign, (-) nuchal rigidity

11. II. COURSE IN THE WARD
DATE PROBLEM ORDER
Admission day
January 27, 2018
11:30 AM
NOI: Vehicular Accident
POI: San Fernando City, La Union
DOI: January 27, 2018
TOI: 11 AM
(-) Loss of Consciousness
(-) AB
(+) Abrasion Right Knee
(+) Closed Fracture
VITAL SIGNS:
BP: 140/60
RR: 19
PR: 111
T: 36. 3 C
Os Sat.: 96 %
Wt: 62.6 kg
• Admit to ROC
• Secure consent of admission and
management
• DAT diet
• TPR q shift and record
• VS q 4 and record
• IVF: PNSS 1 L x 12 hours
• Diagnostics:
12 L ECG
XR of the Right Leg
LSV APL
CBC blood typing
• Therapeutics:
Ketorolac 1 amp/IV now
Celecoxib 200 mg, BID
Wound care

12. XRAY RIGHT LEG

13. LSV APL (1/27/18) CXR (1/27/18)

14. COMPLETE BLOOD COUNT
• Hgb: 129 (127-183)
• Hct: 0.38 (0.40- 0.50)
• WBC: 22.3 (5-10 x10 9)
• Segmenters: 0.71 (0. 50-0.70)
• Eos: 0.01 (0. 000- 0.05)
• Lymp: 0.22 ( 0.20- 0.40)
• Mono: 0.05 ( 0.00- 0.07)

15. DATE PROBLEM ORDER
2: 40 PM Ortho notes:
s/o : seen and examined 61 y/o patient with
a history of motorcycle accident
NEURO: GCS 13 E4V4M5
(+) sleepiness
• Diagnosis: Closed fracture tibia right
• Diagnostics/therapeutics:
XRay pelvis AP
Start cefuroxime 750 mg IV q 8 ( ) ANST
Gentamycin 80 mg IV q 12

16. XR PELVIS APL (1/27/18)

17. DATE PROBLEM ORDER
• Refer for Surgical Evaluation and Co-
management
• Refer for Neurosurgical Evaluation and
co-management
• Post mold applied
• For head CT scan
• IFC now, I and O monitoring
• Ranitidine 50 mg IV q 8 hours
• Please admit patient to ICU for close
monitoring

18. DATE PROBLEM ORDER
3:45 PM BP: 80/60 • NPO temporarily
• Fast drip another 500 cc
• Plain LRS now
• Ketorolac 30 mg IV q 8 hours
4: 00 PM • Patient evaluated
• History of motorcycle accident, a few
hours prior to admission, arrived with
hypertension
• PE:
• noted deformity of right lower
extremity
• Abdomen: noted distended, soft non-
tender
• IFC: Urine clear, (-) blood
• Monitor VS q 4 and record q 30
minutes
• Refer if BP falls below 80/60
• Run present IVF as PLRS 1 Lx 60
gtts/min

19. DATE PROBLEM ORDER
• Monitor VS q 4 and record q 30 minutes
• Refer if BP falls below 80/60
• Run present IVF as PLRS 1 Lx 60 gtts/min
Surgery notes:
• Consume all ongoing IVF, then change to same IVF
with 60 gtts/min
Ortho Notes:
• XRay of Pelvis: bilateral column fracture of
acetabulum right
• Schedule patient for debridement and Irrigation tibia
and application of femoral skeletal traction
• Secure consent for the procedure
• Please transfuse 2 units PRBC properly typed and
cross matched

20. DATE PROBLEM ORDER
6: 10 PM Post OP Order
• To ICU-Head of the Bed at 30 degrees, NVS q
15 min until stable then q 1hours
• O2 @ 2 lpm
• NPO temporarily
• IVF x 40 gtts/min
• IVF to follow:
• PNSS 1 L x 6 hours
• PNSS 1 L x 8 hours
• PNSS 1 L x 8 hours
• Transfuse blood ASAP, Whole blood if extraction
date is < 3 days
• Diphenhydramine 25 mg IV pre BT
• Continue Cefuroxime and Ranitidine
• Discontinue Gentamycin and Ketorolac,
Dobutamine

21. DATE PROBLEM ORDER
• Parecoxide 40 mg IV q 12 hours x 4 doses
• Paracetamol 300 mg IV q 4 hours x 4 doses
the q 6 hours x 2 days then PRN for pain
• Tramadol 50 mg IV + 10 cc IVF slow IV q 6
hours x 2 days then PRN for pain
• For Na, K, Crea, Protime, platelet, FBS , Hgt
• Continue Vitamin K 10 mg IV q 8 hours
• 3more doses
• Continue Tranexamic 500 mgIV q 6 hours x
3 more doses
• I and O q shift
• Refer to ENT for co-management due to
fracture of Condylar process of left mandible

22. DATE PROBLEM ORDER
• Attach Balkan frame to Bed
• Place Right lower extremity in traction , wt.
@ 16 lbs
7:15 PM • Please get HBA1c, BUN, Crea, if not yet done
9: 15 PM (+) restless • Give Midazolam 1 mg q 2 hours
• PRN for severe restlessness only
• Repeat protime, platelet count, Hgb, Hct 8 hours
post BT
January 28, 2018
8:30 AM
ORTHO NOTES:
• Maintain traction
• Continue medications
9:00 AM PE: Not distended, soft, non-
tender
BP: 110/70
• May resume DAT
• Continue medications
3: 00 PM • Soft diet pan
• Avoid jaw movement/chewing
• Continue Anti-inflammatory medications
• Warm compress over post auricular area

23. DATE PROBLEM ORDER
4:30 PM Hgb: 85
Hct: 25
• Transfuse 3 more units of complete whole blood
or PRBC if OK with AP
• Shift facemask to O2 at 1-2 Lpm
• If tolerated may remove
6:45 PM HBA1c: 6.6
Tolerating soft diet
• Strict Aspiration precaution
• For Hgt monitoring TID
January 29, 2018
3: 00 PM
Awake
GCS 15
PE: soft abdomen
• Patient for Transout to regular room
• Discontinue Parecoxib and Tramadol IV
January 30, 2018 • Discontinue Ranitidine IV
• Omepron 40 mg OD
11: 05 AM O2 sat: 92-93 % • Maitain O2 at 2-3 lpm
• Aspiration precaution please
• Refer if there is persistent dyspnea
3:00 PM GCS 15 • Suggest O2 out

24. DATE PROBLEM ORDER
4:55 PM (+) mild DOB
(-) chest pain, not in distress
(-) cough
Awake , conscious
C/L: (+) crackles, left lung field
• Nebulize with salbutamol + Ipratropium now
11: 55 PM BP: 120/80
CR: 122
RR: 31
O2 sat: 84 %
(+) DOB: chest pain
C/S: awake , conscious
C/L: (+) rales in Bilateral lung
field, (+) wheezes
Abdomen: Globular, soft,
NABS, no tenderness
• Change NC to facemask at 5 Lpm
• Ipratropium nebulization now
• Refer for pulmo-evaluation/management

25. DATE PROBLEM ORDER
Impression:
Pulmonary Embolism
secondary to Vehicular
accident
Rule out NSTEMI
PULMO notes:
• For ABG now
• Cardiac profile triage
• 12 L ECG
• CXR portable AP view
January 31, 2018
7:20 AM
• Repeat CBC and save blood
7: 30 AM (+) restless • ABG 1 hour post intubation and relay result
• Midazolam 5 mg IV now
• PULMO IMP: Pulmonary Embolism
• Refer for Cardio management
8:20 AM (+) restless • Incorporate 25 mg Midazolam to 45 ml
D5W/PNSS to run at 2.5 ml/hr up to maximum of
6 ml/hr

26. 9:00 AM  Explained pulmonary
condition of patient to
patient’s children
Maintained on mechanical ventilation – we’ll admit
ABG result
Maintain spO2 >94% at all times
While we cant continue LMWH enoxaparin, try
soludexide (vessel one) OD TID
Close watch please
Continue PPI please
For ETA GSCS
11:00 AM ABG (100%)
7.266/33.5/138/14.9/99
Metabolic Acidosis with Acute
Respiratory Acidosis with
hypoxemia on 100% FiO2
If tolerated, pls add PEEP of 5cmH2o and maintain
RR=16, TV=450
Please repeat result creatinine today and relay CBC
11:09 AM Ortho – continue meds
12:55 AM Strict I&O please

27. 2:40 PM
(+) bleeding via NGT
BP= 100/60
CR=116
Assessment
A. Acute Respiratory S/p Intubation secondary to
1. Acute pulmonary edema/congestion following
myocardial infarction
2. Acute pulmonary embolism
3. ARDS
4. Pneumonia
A. Anemia secondary
B. Physical injury secondary to motor vehicular
accident S/P ORIF
Give diazepam 2.5mg IV now
Start Levophed 80mg in PNSS 100cc to run for24
hours titrate by 2cc/hr to maintain SBP of 120-
130mmHg
Furosemide 40mg IV now then q8 hold for SBP <
100mmHg and refer
Agree to hold enoxaparin
Continue trimetazidine 35mg/tab 1 tab BID

28. Start Losartan 50mg/tab 1 tab BID
Suggest to transfuse 1 PRBC over 6 hours
NPO for now except meds
Start multidex 500cc x 24 hours OD while on NPO
Decrease IVF to KVO (PNSS 1L)
CBG TID HS while on NPO
For CBG <100mg/dl give d50w 50cc IV then repeat
CBG after 30minutes and relay
Discontinue celecoxib tablet, give dolcet 1 tab q8
instead.
Refer for persistent pain

29. TIME  PROBLEM ORDER
6:00 PM ABG at 6:00PM today and 6:00AM tomorrow
Repeat CXR tomorrow morning
11:09 AM Ortho – continue meds
12:55 AM Strict I&O please

30. CARDIAC PROFILE
TRIAGE
• CK MB: 7.6 ng/ml
• Myoglobin: 376 ng/ml
• Trop I : 0.57 ng/ml
• BNP: 766pg/ml
• D dimer: 4860 ng/ml
pH: 7.422
pCo2: 18.1 (Decrease)
- pO2: 48
-HCO3: 11.5 (Decrease)
-SpO2: 86 %
Chronic Respiratory Alkalosis and Severe
hypoxemia (* Intubated)
ABG

33. CXR (1/31/18)

34. DATE PROBLEM ORDER
1:00 PM BP: 120/90
CR: 125
RR: 30; O2 sat: 91 %
@5 Lpm
(+) persistent dyspnea
(-) chest pain
(+) occasional cough
C/L: (+) rales Both lung field
(+) wheezes
Cardiac: AP, NRRR, (-) murmur
Extremeties: (-) edema
• Transfer patient to ICU now
• Give Enoxaparin 0.6 SQ every 12 hours
• Suggest shift Cefuroxime to Meropenen
(Syrapen) 1 g IV q 8 hours ( ) ANST
• Lactulose 30 cc at bedtime to produce 1-2 stools
per day
• Nebulize with Ipratropium bromide + Salbutamol
(Combivent) 1 neb at 12 am- 6 am-10 am
• Budesonide nebulization, 1 neb every 8 hours
• Trimetazidine 35 mg/tab , 1 tab 2x a day

35. DATE PROBLEM • ORDER
t/c Pulmonary Embolism • Increase o2 to 10 L via Facemask to attain O2 sat
of more than 95 %
• Intubate when necessary
• Repeat ECG, Trop I, ABG, SGPT, BUN, CRea, Na, K
, at 6:00 AM
• NAC 600 mg (Exflem) 1 tab to dissolve in ¼ glass
of water to be given at bedtime
• WOF: persistent dyspnea, Desaturation or any
episode of chest pain
1: 20 PM (+) DOB
RR: 32
• Patient intubated
• Hook to MV
• FIO2: 100
• RR: 16
• TV: 420
• AC mode

36. DATE PROBLEM • ORDER
ET: Bloody secretions
ABGs:
pH: 7.387
pCO2: 21.4
pO2: 59
HCO3: 12.6
SpO2: 91
Metabolic Acidosis and Chronic
respiratory Alkalosis and Hypoxemia
ABGs:
pH: 7.422
pCO2: 18.1
pO2: 48
HCO3:11.5
SpO2: 86
Chronic respiratory alkalosis and severe
hypoxemia (* Intubated)
CXR: Patchy infiltrates > right, bilateral
D Dimer: 4860
PULMO NOTES:
Present working impression:
1: Pulmonary Embolism secondary to VA
2: Pneumonia- ARDS vsEdema
•Discontinue Enoxaparin temporarily
•Continue meropenem1 g IV q 8 hours ANST ( )
•Start Clarithromycin 500 mg 1 tab OD
•Continue NAC 600 mg, dissolve 1 tab in ¼ glass water BID
•Continue nebulization; Ipratropium bromide + Salbutamol
( Combivent) 1 neb 6-12-6-10
•Budesonide 1 neb q 8 hours

37. DATE PROBLEM • ORDER
2:40 PM
(+) bleeding via NGT
BP= 100/60
CR=116
Assessment
A. Acute Respiratory S/p Intubation secondary to
1. Acute pulmonary edema/congestion following myocardial
infarction
2. Acute pulmonary embolism
3. ARDS
4. Pneumonia
5. Anemia secondary

38. DATE PROBLEM • ORDER
B. Physical injury secondary to motor vehicular accident S/P ORIF
• Give diazepam 2.5mg IV now
• Start Levophed 80mg in PNSS 100cc to run for24 hours titrate by
2cc/hr to maintain SBP of 120-130mmHg
•Furosemide 40mg IV now then q8 hold for SBP < 100mmHg and refer
•Agree to hold enoxaparin
•Continue trimetazidine 35mg/tab 1 tab BID
•Start Corason 5mg/tab 1 tab BID
•Suggest to transfuse 1 PRBC over 6 hours

39. DATE PROBLEM • ORDER
•NPO for now except meds
•Start multidex 500cc x 24 hours OD while on NPO
•Decrease IVF to KVO (PNSS 1L)
•CBG TID HS while on NPO
•For CBG <100mg/dl give d50w 50cc IV then repeat CBG
after 30minutes and relay
•Discontinue celecoxib tablet, give dolcet 1 tab q8 instead.
•Refer for persistent pain

40. DATE PROBLEM • ORDER
4:50 PM O2 sat: 99 % •Ventilator setting:
•FIO2: 90 % + 5 cm H2O PEEP
•TV: 450
•RR: 16
•ABG at 6 PM and relay
•Continue Clarithromycin 500 1 tab OD
•Continue NAC 600 mg BID
•Please do CPT by percussion c/o RT
•Repeat CXR portable tomorrow 6 AM
•Repeat ABG by 6 AM tomorrow
6:00 PM •ABG at 6:00PM today and 6:00AM tomorrow
•Repeat CXR tomorrow morning
6:30 PM •May maintain Midazolam drip at 2.5 cc/hr and may
start weaning off tomorrow (2 PM if patient is not
restless)
9:30 PM •Start nebulization with Ambroxol respiratory
solution plus equivalent amount of NSS q 8 hours,
start now
•Increase PEEP to 10 cm H2O
•Discontinue Budesonide nebulization
•Shift neb to Combivent + equivalent amount of NSS
q 8 hours
•Adjust Norepineprine drip if hypotensive

41. DATE PROBLEM • ORDER
9:00 AM ABG
7.5/28.3/211/21.6/100%
FiO2=100%
BP=130/80
CR=97
SpO2= 100%
Acute Respiratory Alkalosis
Mild Hypoxemia at 100% FiO2
and PEEP
(+) fever
(+) still bloody secretiom
Please include platelets and protime
Please schedule for FOB today – please inform
Dr.NNR
Meropenem (Syropen) 1 gram IV q8 via soluset
Please do CPT by percussion c/o RT TID
Vitamin K 1 amp IV now
10:50 AM Include Crea, Na, K on blood taken this AM
To ICU
Attach d5w to previous soluset
VS q15 until stable then q4h
May start OF 1500 in a divided dinner
IVF /meds as ordered
Shift to tramadol oral to IV 50mg + 10cc IVF IV q6 x
3days then more for pain
Midazolam drip x 1 more day start weaning
Inform AP

42. DATE PROBLEM • ORDER
February 02, 2018
7:40 AM
Still febrile 39.2 C
FIO2 80 % PEEP 10
ABG now
Chest portable now
Increase paracetamol to 600 mg IV RTC every 4
hours
Follow up C and S result and chest x ray official
reading
8:30 AM ABGs as 90 % + 10 PEEP
pH: 7.455
pCO2: 35.3
pO2: 359
HCO3: 24.3
SpO2: 100 %
Within acceptable ABGs with
slightly corrected hypoxemia as
90 % with 10 PEEP
Decrease FIO2 to 80 % with 10 PEEP and maintain
rest of setting
Start Clindamycin 600 mg IV q 6 hours
Repeat ABG by 1 PM and relay
pH: 7.424
pCO2: 42.1
pO2: 167
HCO3: 26.9
SpO2: 100 % at 80 % FIO2 + 10
PEEP
Within acceptable ABGs with
corrected hypoxemia
Start Co-trimoxazole 800 1 tab BID
Continue Meropenem 2 g IV q 8 hours, continue
clindamycin 600 mg q 6 hours
Please ff up ETA C/s result
Decrease FIO2 to 70 % , maintain 10 cm H20 PEEP
and rest of setting

43. DATE PROBLEM • ORDER
3:12 PM BP=120/70
CR=89
Continue with levophed
Once OF is started, consume multidex then
discontinune
Adjust Coraline Fobradine to 7.5mg/tab 1 tab 7am
then 5mg/tab 1 tab 7pm
Discontinue CBG monitoring once on OF feeding
3:55 PM Dolcet 1 tab every 8hrs PRN for pain

44. DATE PROBLEM • ORDER
February 03, 2018
10:45 AM
Patient reintubated due to out
ET
CR: 60’s
O2 sat: 40’s
CR:40’s
CR: 0
CR: 0
BP: 0
Pupils fixed dilated
Patient intubated
ET size 7.5 at level 22
Please give Atropine 1 amp now
CPR started
Hook to continues ambubagging
Epinephrine 1 amp IVq 3 minutes x 10 doses
Patient pronounced dead at 10: 45 AM
Post mortem care
Notify AMD’s

45. ABGs
pH: 7.387
pCo2: 21.4
- pO2: 59
-HCO3: 12.6
-SpO2: 91 %
Metabolic Acidosis and Chronic respiratory Alkalosis
and Hypoxemia
BUN: 4.8 (3.0-9.2)
Creatinine: 83.2
Potassium 3.2
Sodium 142

46. PERTINENT FINDINGS
Subjective Objective
Major trauma
Prolonged Immobilization
Chest pain
Dyspnea
Age (61)
(+) Rales
(+) wheezes
XR:Fracture lower extremities (Tibia, Fibula)
CXR: Pulmonary edema
Elevated D –dimer
ABG: Respiratory Alkalosis

47. FINAL DIAGNOSIS
• Cerebral concussion;
• Fracture: Acetabulum; Ant-post column; Posterior wall; Comminuted;
• Fracture ClosedTibia right leg;
• Fracture: closed, transverse fibula, right leg
• Pulmonary Embolism;
• Ischemic Heart Disease with myocardial infarction
• Acute Respiratory Failure secondary to Pneumonia with hypoxia;
• Complete Fracture of condylar process (L) mandible

48. DIFERENTIALS
1. Subarachnoid Haemorrhage secondary to Cerebral concussions
2. Pulmonary Embolism secondary to fracture
3. Acute Respiratory Failure secondary to Pneumonia with Hypoxia
4. Ischemic Heart Disease with Myocardial Infarction

49. DIFFERENTIALS RULE IN RULE OUT
1. Pulmonary Embolism (+) dysapnea
(+) Tibia/fibula Fx.
(+) Chest pain
(+) Pulmonary Edema
(+) Rales, wheezes
(-) spiral CT
(-) pulmonary Angiograph
(-) 2d Echo
2. Myocardial Infarction (+) chest pain
(+) ECG evidence- T wave
inversion
(+) Trop I
3. Subarachnoid Hemorrhage (+) CT evidence – mild
hemmorhage, parietal lobe

50. DISCUSSION
• PE is the most common preventable cause of death among hospitalized
patients.

51. Pathophysiology
At least 90% of pulmonary emboli originate
from major leg veins.

52. EPIDEMIOLOGY
• VTE after major Trauma 60 % (European Heart Journal)
• Incidence of deep venous thrombosis is reported as between 1% and 2 % following fracture of the long bones
• increased to between 1% and 3% in the presence of obesity
• The risk of pulmonary embolism (symptomatic or asymptomatic) with proximal vein thrombosis is approximately 50%.
• Source: L. Chen, D. Soares (From Logan Hospital, Queensland, Australia) Fatal pulmonary embolism following
ankle fracture in a 17-year-old girl, a case report/ European Heart Journal, 2014

53. LOWER EXTREMITY DVT
• usually begins in the calf and propagates proximally to the popliteal vein,
femoral vein,
• and iliac veins.
• Leg DVT is about 10 times more common than upper extremity DVT, which is
often precipitated by placement of pacemakers,
-internal cardiac defibrillators, or
- indwelling central venous catheters.

54. PREDISPOSING FACTORS
• Malignancy
• Prolonged bed rest
• Long-haul air travel
• Obesity
• COPD
• Systemic arterial HTN
• Smoking
• OCPs
• Pregnancy
• Surgery & trauma
• Post menopausal hormone replacement
• Thrombophilia, AF

55. HEREDITARY FACTORS
• Antithrombin III deficiency
• Protein C deficiency
• Protein S deficiency
• Factor V Leiden
• Plasminogen abnormality
• Fibrinogen abnormality
• Resistance to activated Protein C

56. PATHOPHYSIOLOGY
• Embolization
• Impaired gaseous exchange
• Increased pulmonary vascular resistance
• Increased airway resistance
• Decreased pulmonary compliance

57. CONTD…
As pulmonary vascular resistance↑, RV wall tension ↑ & causes further RV
dilation & dysfunction
↓
↑ RV wall tension also compresses the
RCA
↓
↓ subendocardial perfusion & limits myocardial oxygen supply
↓
Provokes MI → eventually circulatory collapse & death may ensue
Ref : Harrison’s Principles of Internal Medicine, 18th Ed

60. VIRCHOW’S TRIAD

61. CLINICAL FEATURES
• Dyspnea (m/c)
• Pleuritic chest pain (sudden & sharp)
• Substernal chest pain
• Cough
• Fever
• Hemoptysis
• Syncope

62. CONTD.
• Unilateral leg pain (signs of DVT)
• Diaphoresis
• Tachycardia, Tachypnea
• Hypoxemia (paO2 < 8ommHg)
• S3 or S4 gallop/cardiac murmur

63. CLINICAL PRESENTATION DEPENDS UPON SIZE
OF PE
Risk Factor Small PE
(70-75%)
Moderate PE
(20-25%)
Massive PE
(5-10%)
Usual symptoms Pleuritic chest pain,
cough, hemoptysis
varied Dysapnea, syncope
Usual signs varied varied Hypotension, cyanosis
Blood Pressure Normal Normal Low (<90 mmhg SBP)
RV on 2D echo Normal Hypokinesis/dysfunction Hypokinesis/dysfunction
Mgmt. Anticoagulation: Heparin
+ warfarin; or
Rivaroxaban
IV anticoagulation:
controversy regarding
advanced
IV anticoagulation: consider
advanced therapy

64. DIAGNOSIS
Source: Harissons 19th edition

65. RESPIRATORY FAILURE
• A condition in which the respiratory system falls in one or both of its gas
exchanging functions
- oxygenation
-CO2 elimination

66. RESPIRATORY FAILURE
TYPE REMARKS
I Acute hypoxemic (Pao2; <55-60 mmHg)
From alveolar flooding and/or intrapulmonary shunting
-Pulmonary edema, pneumonia, alveolar hemorrhage, ARDS
II Hypercarbic (PCO2>45-55mmhg), alveolar hypoventilation
Diminished CNS drive to breathe
-Drug overdose, brainstem injury, sleep disorders, hypothyroidism
Reduced Neuromuscular strength
-Myasthenia gravis, GBS, ALS, Phrenic Nerve injury, Myopathy, Fatigue, Electrolyte
abnormalities
Increased load to respiration
-Bronchospasm, Alveolar edema , Atelectasis, Pneumothorax, Pleural Effusion, PE, Sepsis
III Result of atelectasis
Perioperative RF
IV Results from Hypoperfusion of respiratory muscles in shock
Intubation and mechanical ventillation allow redistribution of cardiac output away from
respiratory muscles and back to other vital organs while shock is treated

67. DIAGNOSTIC FINDINGS OF PE
Chest X Ray
• Radiographic signs include:-
• Fleishner sign: enlarged pulmonary artery (20%)
• Hampton hump: peripheral wedge of airspace opacity and implies lung
infarction (20%)
• Westermark's sign: regional oligaemia and
highest positive predictive value (10%)
• Pleural effusion (35%)
• Knuckle sign
Ref : http://radiopaedia.org/articles/pulmonary-embolism

71. CONTD… ECG
• Sinus tachycardia – m/c abnormality
• Complete or incomplete RBBB – a/w ↑ mortality
• RV strain pattern – T wave ↓ in the right precordial
leads (V1-4) ± the inferior leads
• Right axis deviation
• Right atrial enlargement (P pulmonale)
– peaked P wave in lead II > 2.5 mm in height
• Atrial Tachyarrhythmias – AF, Flutter
• Non specific ST-segment & T wave
changes

73. CONTD…
• CT Pulmonary Angiography (CTPA)
• filling defects within the pulmonary vasculature with acute
pulmonary emboli
• When observed in the axial plane this has been described
as the polo mint sign

74. CONTD…

75. OTHER INVESTIGATIONS :-
• ECHO - It helps to detect RV enlargement &
RWMA a/w PTE
(McConnell’s sign - hypokinesia of RV free wall with
normal motion of RV apex is best known indirect sign
of PE)
• ABG - ↓ PaO2
• D- Dimer assay
• NT Pro BNP
• V/Q Scan
• Venous USG & Impedence
Plethysmography
• Contrast enhanced Helical CT Lung

76. DIAGNOSTIC APPROACH

77. MANAGEMENT
• Provide O2 by cannula/mask/ventilator – as indicated
• Elevate head-end of bed
• Elevate lower extremities if DVT is present
• Morphine to manage pain & anxiety (avoid in case of severe
Hypotension)
• Inj. Heparin 10,000 U i/v bolus followed by 5000 U i/v 6 hourly
charged in 200 ml N/S
• LMWH (Enoxaparin 1mg/kg BD s/c)
• Dopamine or Dobutamine infusion to treat hypotension & shock

78. DIFFERENT LMWH IN USE
Name Treatment Dose
Enoxaparin
1 mg/kg twice daily (approved as an
inpatient or outpatient dose), or 1.5
mg/kg once daily (inpatient dose only)
Dalteparin
100 units/kg twice daily, or
200 units/kg once daily
Tinzaparin
175 units/kg once daily

79. PULMONARY EMBOLECTOMY
• Emergency surgical removal of emboli which are
blocking blood circulation & causing necrosis

80. VENA CAVA FILTER
•
• Type of vascular filter, a medical device that is implanted
into the inferior vena cava to presumably prevent life-
threatening pulmonary emboli

81. PREVENTION
• Leg exercises (Dorsiflexion of feet)
• Frequent position changes
• Ambulation
• Intermittent pneumatic leg compression
devices
• Anti embolism stockings
• Tab.Warfarin 5mg BD x 3-4 weeks & then can be tapered
to keep INR @ 2.5-3

82. REFERENCES
• Tintinalli’s Emergency Medicine e-Book 6th Edition
• Harrison’s Principles of Internal Medicine 18th
Edition
• European Heart Journal, 2014
• radiopaedia.org/articles/pulmonary- embolism

83. THANK YOU  