4. Pulmonary Embolism,
Infarction
• Embolism : Impaction of a thrombus or
foreign matter in the pulmonary
vascular bed.
• Infarction : The pathological changes
which develop in the lung as a result of
pulmonary embolism.
5. Pulmonary Thrombo-
embolism
• Thrombosis of peripheral veins ,
embolization of pulmonary arteries ,
and pulmonary infarction.
• Primary thrombosis in pulmonary
arteries and veins
6. Pulmonary Embolism, Prevalence
• PE : The cause of, or a major contributory
factor to, death in 7-9% of necropsy cases
• PM Pul. Angiographic technique : 14-18%
• Considering smaller thrombi : 60%
• PE is a major contributory factor to death
in 50 000-200 000 patients per year in
USA
8. Pathogenesis of Vascular
Thrombosis
• Decrease in blood flow below a certain
critical level.
• Increase in coagulability of blood.
• Damage of the vessel wall.
9. RISK FACTORS
• Bed rest
• Post-operative
• After severe
blood loss and
trauma
• CHF
• Varicose veins
• Advancing age
• Obesity
• Post-partum
• Malignancy
• DM
• Pneumonia
• Debilitating
diseases
• 1ry polycythemia
• Race, Diet
10. PE, Clinical Features
• Size of the embolus and blood
vessel occluded.
• State of the lung.
• Associated disease(s).
11. PE , Clinical Features
• Massive Pulmonary Embolism ( MPE )
• Pulmonary Infarction ( PI )
• Obliterative Pulmonary Hypertension
12. Massive Pulmonary Embolism
MPE
• CLINICAL SETTING
• ELDERLY,POSSIBLY OBESE
• AROUND THE 10th
DAY POST-OP.
• CALLING FOR BED-PAN
• EXPIRING SUDDENLY OR WHILE
IN THE ACT OF DEFECATION
• IMMEDIATELY FATAL,2/3 DIE IN
THE FIRST TWO HOURS
39. Pulmonary Infarction, Clinical
Picture
• Pleuritic chest pain, Pleural rub,
Pleural effusion
• Hemoptysis: in only 50% of cases
• Finding the source of
embolization: in only 60% of cases
• Tachcardia( more than 100/ min )
Tachypnoea
• Jaundice, Cyanosis
40. Pulmonary Infarction, Clinical
Picture
• Locally: No Physical
Findings, Consolidation,
Diminished Intensity of
Breath Sounds, Crepitus,
Wheezing Chest
• Pleural Rub
• Signs of Pleural Effusion
41. Pulmonary Infarction, Clinical
Picture
• With Infection: Worsening of the
Clinical Status: Abscess or
Empyema
• Persistent Fever, Malaise,
Sweating
• Increasing Pulse Rate
• Leucocytosis more than 20 000
• Chest X-Ray
42. Clinical Features of PTE
Silent Asymptomatic Probably more
frequent than we
realize
Without Infarction Breathlessness,
Tachycardia,
Anxiety,
Restlessness
Usually Transient
43. Clinical Features of PTE
With Infarction Dyspnea,
Hemoptysis,
Pleutitic Pain,
Friction Rub,
Fever,
Brochospasm.
If you wait for
these features,
you will miss
perhaps 60% of
patients with
embolism
44. Clinical Features of PTE
With
Hemodynamic
Impairment
Angina,
Tachycardia,
P++, Gallop,
JVP++,
Hypotension,
Cyanosis,
Syncope
This means
obstruction of
30-50% of
pulmonary
vascular bed
45. Value of Diagnostic Tests in PTE
Chest X-Ray Elevated Diaphragm,
Wedge-shaped
opacity, Atelectasis,
Pleural Effusion
It may be Normal
after acute PE
ECG Sinus Tachycardia,
S1, Q3, T3, Rt. Axis
P-Pulmonale,
Incomplete RBBB ,
Arrhythmias
Chest X-Ray and
ECG should be
Routine
46. Value of Diagnostic Tests in
PTE
Isoenzyme
Pattern
Normal Only helpful
in
distinguishing
PE from MI
Leucocytic
Count
Under 15 000 If over 15 000,
consider
Bacterial
Sepsis
47. Value of Diagnostic Tests in
PTE
Arterial Blood
Gases ( ABG )
Hypoxemia,
Hypocapnia
Non-specific
Alveolar-
Arterial
Oxygen
Tension
Difference
Increased
Difference
More
Sensitive but
Non-specific .
48. Value of Diagnostic Tests in
PTE
Radioactive
Scanning
Abnormal Lung
Perfusion with
Normal
Ventilation .
High,
Intermediate
and Low
Probability .
Non-specific,
Too many
False-positive .
A Normal
Perfusion Scan
with a Normal
CXR rules out
PE .
49. Value of Diagnostic Tests in
PTE
Pulmonary
Angiogram
Intravacular
Filling Defect or
Vessel Cut-off
The Most
Reliable but
Invasive
D-Dimers A Good Negative
Predictive Test
Elevated in DIC,
Pregnancy,
Severe Infection,
Trauma,
Malignancy,
Surgery, Liver
Disease
50. Value of Diagnostic Tests in PTE
Spiral Computed
Tomography
•Comparable to
Angiography.
•Cases with
Ventilation-
Perfusion scan of
Intermediate
Probability
Poor Quality may
be obtained as a
result of motion
artifacts.
Clinical
Assessment
Clinical Scoring
Plus ECG,
Radiographic
Findings,
Perfusion Scan.
This may restrict
the need for
Angiography to a
minority.
51. Clinical Probability of PE
• High Probability ( 90% ): Presence of at
least one of three symptoms ( Sudden
onset Dyspnea, Chest Pain, or Fainting )
not explained otherwise and associated
with : (1) Any two of the following
abnormalities: ECG signs of RV
overload, Radiographic signs of
Oligemia, Amputation of hilar artety, or
Pulmonary consolidations compatible
with infarction; (2) Any one of the
above three radiographic abnormalities.
52. Clinical Probability of PE
• Intermediate Probability (50%):
Presence of one of the above
symptoms, not explained
otherwise, but not associated with
the above ECG and Radiographic
abnormalities, or associated with
ECG signs of RV overload only.
53. Clinical Probability of PE
• Low Probability (10%): Absence
of the above three symptoms, or
identification of an alternative
diagnosis that may account for
their presence (e.g.,exacerbation of
COPD, Pneumonia, Lung Edema,
Pneumothorax, Myocardial
Infarction, and others).
55. •The Combination of A
High-Probability
Ventilation-Perfusion
Scan Plus A High Clinical
Suspicion is Diagnostic for
Pulmonary Embolism.
56. •A Low-Probability or
Normal Lung Scan with a
Low Clinical Suspicion
makes the diagnosis of
Pulmonary Embolism
Unlikely
57. •Spiral CT is A Primary Diagnostic
Modality in Suspected Pulmonary
Embolism.
.It is the Diagnostic Test of Choice when
Ventilation-Perfusion Scans are judged to
be Intermediate.
58. Massive Pulmonary Embolism MPE
• 2/3 die in the first 2 hours.
• A Medical Emergency.
• Resuscitate : Succeed : Pulmonary
Angiography.
• Less than 75% decrease in peripheral
perfusion : Streptokinase.
• 75% or more decrease in peripheral
perfusion : Embolectomy.
59. Massive Pulmonary Embolism MPE
Recombinent-tissue type
plasminogen activator ; t-PA
Altepase : 100mg over 2 hours.
60. Pulmonary Embolism, Prevention
• Patients at risk: Early Ambulation.
• Risk Factors.
• During Operations.
• Prophylactic Heparin.
• Vein Ligation.
• Filters.
63. Streptokinase
• 600 000 U in 1/2 h,
• Then 100 000 U/h for 72h.
• Thrombin clotting time.
• EACA: Local and Systemic, Fresh Blood,
and Fresh Frozen Plasma.
64. Heparin
• 15 000 - 25 000 U iv Bolus,
• Then 40 000 - 60 000 U/ 24 h, or 20
U/Kg/h
• Partial Thromboplastin Time ( PTT ).
• Infusion Pump.
• Absolute and Relative Cotraindications.
• Protamine Sulphate.
