1. “The double edged sword”

2. The story Mr. CP and his wife Auto mechanic hjhkjh

4. Hypertension

5. Hyperlipidemia

7. The story

8. The story 2 weeks ago…

9. The story Gastritis. Gastric ulcer with clean base – Bx shows no malignancy or H. Pylori. No active bleeder or exposed vessel – low risk for rebleed.

11. Hypertension

12. Hyperlipidemia

13. 3 stents in 2001 & 1 more stent in 2004Penicillin, Plavix DM Type II, HTn Cigarette – quit at 30s, <1ppd No alcohol/ IVD

14. Physical Vitals – 121/74, 58/min reg, 18/min, 97%, 98F Normal examination.

15. Differential

16. Relevantlabs

17. EKG Normal sinus rhythm RBBB (old) No new ST-T changes

18. Imaging

19. Pulmonary thromboembolism

20. Incidence in United states…1 per 1000 2nd commonest cause of sudden death 3rd commonest cause of death in hospitalized patients 60% of hospital deaths had PE on autopsy – 70% of these were missed DVT of LE is asymptomatic in >50%

21. 400,000 cases missed every year in US 100,000 deaths could be prevented with Dx & Rx

22. Pathophysiology

23. Pathophysiology Usually originates near valve cusp. Most calf vein thrombus resolve spontaneously. 20-30% may extend up to involve poplitel, femoral or iliac. Rarely from pelvic, renal, upper extremity. Emboli travels to lower lobes more frequently.

25. Hyperventilation not

26. Pneumoconstriction universal

27. Regional loss of surfactant finding

29. Risk factors Immobilization Surgery, trauma, burns Pregnancy Oral contraceptives, Estrogens Malignancy Cardiac failure Polycythemia, Dehydration Factor V Leiden, Antithrombin III/Protein C/S deficiency, Prothrombin mutation PNH, APLA Nephrotic syndrome HIT

30. Clincal Picture

31. Clinical Picture Symptoms: PIOPED study Dyspnea (73%) Pleuritic pain (66%) Cough (37%) Hemoptysis (13%) And then… Seizures Syncope Fever Abdominal pain Productive cough Wheezing Flank pain Decreasing level of consciousness New atrial fibrillation Delirium (in elderly)

32. Clinical Picture Signs: PIOPED study Tachypnea (70%) Rales(51%) Tachycardia (30%) Fourth heart sound (24%) Accentuated P2 (23%) Fever < 39.5 C (14%) And then… Chest wall tenderness, JVD, RV heave, palpable P2, right ventricular S3, systolic murmur over the left sternal border louder during inspiration, hepatomegaly, ascites, dependent pitting edema.

33. Workup Gold standard – Pulmonary angiogram

34. How to approach Wells criteria

35. How to approach CT experienced institutes

36. How to approach CT inexperienced institutes

37. How to approach PE Rule out Criteria (PERC) ALL PERC criteria + Low suspicion for PE (Wells score 0/1 or a low gestalt probability) PE may be excluded without further diagnostics. Cohort study of 8138 ER ptswith suspected PE – 1666 pts fulfilled ALL PERC + Low suspicion for PE - only 15 (<1%) developed a DVT or PE within 45 days.

38. How to approach PE Rule out Criteria (PERC)

39. Treatment Consider initial anticoagulation

40. Treatment

42. If hypotensive/may undergo thrombolysis or if impaired SC absorption – give IV UFH.

43. If creatinine clearance <30 ml/min, give IV or SC UFH.

44. Warfarin may be initiated at the same time – overlap of atleast 5 days – target INR 2.5.

45. 1st PE + temporary risk factor – 3m warfarin.

46. 1st PE + unknown risk – atleast 3m, then reassess.

47. >1 PE – indefinite warfarin.

48. Initiate it in every one with high clinical suspicion of PE and no excess risk of bleed - continue till PE is ruled out.

51. Initiate only if PE is confirmed.

52. Only if SBP <90mm or drop >40mm from baseline AND no risk of excess bleeding.

54. Large perfusion defect on VQ scans

55. Extensive embolic burden on CT

56. Right ventricular dysfunction

57. Free-floating right atrial or ventricular thrombus

59. History of hemorrhagic stroke

60. Active intracranial neoplasm

61. Recent (< 2 months) intracranial surgery or trauma

62. Active or recent internal bleeding in prior 6 months

63. Relative

64. Bleeding diathesis

65. Uncontrolled severe hypertension (>200/110 mmHg)

66. Nonhemorrhagic stroke within prior 2 months

67. Surgery within the previous 10 days

69. Questions? Lijo.John@baylorhealth.edu