Massive pulmonary embolism case presentation

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High suspicion for massive pulmonary embolism can be life saving.

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Massive pulmonary embolism case presentation

  1. 1. MASSIVE PULMONARY EMBOLISM CASE PRESENTATION DR SYED RAZA
  2. 2. <ul><li>35 years old lady teacher </li></ul><ul><li>Living with partner </li></ul><ul><li>Type I DM – on Insulin, Non smoker </li></ul><ul><li>OCP – 6 years </li></ul><ul><li>Suddenly collapsed on doorway while preparing to leave for school. </li></ul><ul><li>Possible LOC , No head injury. Partner called for the ambulance. </li></ul>
  3. 3. IN ER <ul><li>Denied any chest pain or palpitation </li></ul><ul><li>No history of leg pain or swelling </li></ul><ul><li>O/E </li></ul><ul><li>Conscious , oriented </li></ul><ul><li>Tachypnoec R/R 36/mt SpO2 – 84% RA </li></ul><ul><li>HR 128/mt SR BP 94/56 mmHG </li></ul>
  4. 4. <ul><li>Legs – No signs of DVT </li></ul><ul><li>CVS- Normal heart sounds, No rub, possible systolic murmur left para sternal area </li></ul><ul><li>Chest- Lungs – possible decreased air entry left lung but otherwise clear. </li></ul><ul><li>Abdomen and Neuro - Unremarkable </li></ul>
  5. 9. ECHO REPORT <ul><li>Grossly dilated RV </li></ul><ul><li>Severely hypo kinetic RV free wall </li></ul><ul><li>RV apex contracts well </li></ul><ul><li>PASP 55 mmHg </li></ul><ul><li>Rest normal </li></ul>
  6. 10. <ul><li>Impression – Massive PE </li></ul><ul><li>Thrombolysed with ALTEPLASE </li></ul><ul><li>Progress : </li></ul><ul><li>BP improved, tachycardia settled and Sp02 normalised almost immediately. </li></ul><ul><li>Patient transferred to CCU </li></ul>
  7. 11. ROLE OF ECHO IN SUSPECTED PE <ul><li>Not indicated in all suspected PE patients </li></ul><ul><li>Not a diagnostic tool for PE (Indirect evidence only) </li></ul><ul><li>Signs not specific for PE (low sensitivity and specificity) </li></ul><ul><li>Should not be overused – findings may be misleading </li></ul>
  8. 12. INDICATIONS <ul><li>Suspected massive PE </li></ul><ul><li>Patient haemo dynamically unstable </li></ul><ul><li>RV strain on ECG, rise in Troponin or BNP </li></ul><ul><li>Other modes of imaging not readily available </li></ul><ul><li>Patient pregnant and massive PE is suspected </li></ul><ul><li>Immediate Thrombolytic may be indicated </li></ul><ul><li>Follow up studies – To assess RV function and pulmonary artery pressure </li></ul>
  9. 13. Findings – Acute Massive PE <ul><li>Dilated RV ( EDD > 30 mm, RV/LV > 1) </li></ul><ul><li>Akinetic RV free wall but the RV apex contracts well (Mc Connel’s sign) – 77% sensitivity and 94 % specificity </li></ul><ul><li>Raised PASP – not more than 60 mmHg </li></ul><ul><li>Free floating thrombus in RV (rare) </li></ul>
  10. 14. Findings – Chronic PE <ul><li>RV Hypertrophy > RV Dilatation </li></ul><ul><li>RV function – reasonable </li></ul><ul><li>PASP – more than 60 mmHg </li></ul>
  11. 15. CAUSES OF RV ENLARGEMENT <ul><li>a. Tricuspid valve disease </li></ul><ul><li>b. Severe Pulmonary Regurgitation </li></ul><ul><li>c. ASD </li></ul><ul><li>d. Pulmonary HPN – Primary and Secondary </li></ul><ul><li>e. R V Infarction </li></ul><ul><li>f. Arrhythmogenic RV Dysplasia (Cardiomyopathy) </li></ul>
  12. 19. EVIDENCE <ul><li>Heparin vs Streptokinase - only small studies </li></ul><ul><li>Strep: all survived Hep: Non survived </li></ul><ul><li>Alteplase vs Streptokinase (Alteplase more effective) </li></ul><ul><li>Thrombolytic Therapy in patients with stable blood pressure but RV dilatation/dysfunction - Controversial </li></ul>

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