This document discusses pulmonary embolism (PE), including risk factors, symptoms, diagnosis, and treatment. There are inherited and acquired risk factors for PE, such as genetic mutations or advanced age/smoking. Symptoms include dyspnea, tachycardia, and pleuritic pain. Diagnosis involves blood tests, imaging like CT scans, and potentially pulmonary angiography. Treatment involves anticoagulation with drugs like heparin or warfarin, or procedures like fibrinolysis, embolectomy, or IVC filter placement. Prevention focuses on anti-coagulation and mechanical methods like compression stockings.

1. Pulmonary Embolism
陳曉萍

2. Risk Factors
Inherited conditions
Acquired conditions

3. Inherited Factor
• Factor V Leiden mutation
• Prothrombin gene mutation
• Deficiency of antithrombin III, protein C
or protein S

4. Acquired Factor
• Age
• Smoking
• Obesity
• Atherosclerosis disease
• Recent trauma or surgery
• Long-haul air travel
• Oral contraceptives
• Pregnancy

5. Acquired Factor
• Postmenopausal hormone replacement
• Acute infection
• Personal or family history of VTE
• Cancer
• Antiphospholipid antibody syndrome
• Systemic hypertension
• COPD
• Pacemaker or ICD

6. Pathology

7. Symptoms and signs
• Dyspnea
• Tachycardia
• Cyanosis
• Syncope
• Hypotension
• Cardiogenic shock
• Cardiac arrest

8. Symptoms and signs
• Pleuritic pain
• Hemoptysis
• Distended neck veins
• TR
• Accentuated sound of pulmonic
closure

9. Differential diagnosis
• MI
• Pneumonia
• Bronchitis
• Exacerbation of asthma
• COPD
• CHF
• Pericarditis
• Rib fracture
• Pneumothorax
• Primary pulmonary hypertension
• anxiety

12. Lab work up
• Blood work
• ECG
• CXR
• CT
• Echocardiogram
• MRI
• VQ scan
• Pulmonary angiography

13. Diagnosis

14. Treatment
• Fibrinolysis
• Embolectomy
• Catheter-based
embolectomy
• Anticoagulation
• IVC filter

15. Fibrinolysis
t-PA(alteplase)
100mg continuous infusion over 2hours

16. Anticoagulation
Heparin
Bolus 80units/kg
Infusion 18units/kg/hr
Keep aPTT 2-3倍(約60-80seconds)

17. Anticoagulation
Low-molecular-weight heparin(LMWH)-
Enoxaparin
1mg/kg BID or
1.5mg/kg QD

18. Anticoagulation
Fondaparinux
<50kg------5mg
50-100kg------7.5mg
>100kg------10mg

19. Anticoagulation
Warfarin
Heparin、LMWH、Fondaparinux overlap
at least 5days
Keep INR 2.0-3.0

20. IVC filter
Anticoagulation contraindication
Recurrent PE despite anticoagulation

24. Prevention
Mechanical prophylaxis
Graduated compression stockings(GCS)
Intermittent pneumatic compression(IPC)

25. Prevention
Pharmacological prophyxis
Heparin
LMWH
Warfarin
Fondaparinux

26. Regimens for VTE prophylaxis
General surgery：
Heparin 5000units sc TID or
Enoxaparin 40mg sc QD or
Dalteparin 2500 or 5000units sc QD

27. Regimens for VTE prophylaxis
Orthopedic surgery：
Warfarin(target INR 2-3)or
Enoxaparin 30mg sc BID or
Enoxaparin 40mg sc QD or
Dalteparin 2500 or 5000units sc QD or
Fondaparinux 2.5mg sc QD

28. Regimens for VTE prophylaxis
Neurosurgery：
Heparin 5000units sc BID or
Enoxaparin 40mg sc QD and
Graduated compression stocking/intermittent
pneumatic compression
Consider surveillance lower extremity
ultrasonography

29. Regimens for VTE prophylaxis
Oncologic surgery：
Enoxaparin 40mg sc QD

30. Regimens for VTE prophylaxis
Thoracic suregery：
Heparin 5000units sc TID and
Graduated compression stockings/intermittent
Pneumatic compression

31. Regimens for VTE prophylaxis
Medical patients：
Heparin 5000units sc TID or
Enoxaparin 40mg sc QD or
Dalteparin 5000units sc QD or
Fondaparinux 2.5mg sc QD or
Graduated compression stockings/intermittent
pneumatic compression for patients with
contraindications to anticoagulation
Consider combination pharmacological and
mechanical prophylaxis for very high risk patients
Consider surveillance lower extremity ultrasonography for
ICU patients