Dr. Mohammad Ashraful Amin presented on the management of pulmonary embolism. He discussed the diagnostic approach including risk stratification, clinical exams, tests like D-dimer and imaging techniques. He outlined treatment options including anticoagulation with heparin or warfarin as well as thrombolysis. Special considerations for pulmonary embolism in pregnant patients were also covered, along with methods for preventing pulmonary embolism.

1. Dr. Mohammad Ashraful AminDr. Mohammad Ashraful Amin
Cardiology deptCardiology dept
Presentation onPresentation on
Pulmonary embolismPulmonary embolism
managementmanagement

2. TopicsTopics
 •• IntroductionIntroduction
 •• Diagnostic approachDiagnostic approach
 •• Treatment optionsTreatment options
 •• Special circumstances: Pregnant patientSpecial circumstances: Pregnant patient
 •• PreventionPrevention

3. IntroductionIntroduction
 •• Pulmonary embolism (PE) is aPulmonary embolism (PE) is a
medical emergencymedical emergency
 where pulmonary artery or its brancheswhere pulmonary artery or its branches
are blockedare blocked
 with embolic substances most commonlywith embolic substances most commonly
blood clotsblood clots
 •• Most cases are not life threatening.Most cases are not life threatening.

4. Types of PETypes of PE
 •• Massive PE: Acute PE with obstructive shockMassive PE: Acute PE with obstructive shock
or SBPor SBP
<90 mmHg<90 mmHg
 •• Sub-massive PE: Acute PE without systemicSub-massive PE: Acute PE without systemic
hypotension (SBP ≥90 mm Hg) but with either RVhypotension (SBP ≥90 mm Hg) but with either RV
dysfunction or myocardial necrosisdysfunction or myocardial necrosis
 •• Non-massive or low risk PE: None of theNon-massive or low risk PE: None of the
aboveabove
 severe featuressevere features..

5. PathophysiologyPathophysiology
 Deep vein thrombosis from large veinDeep vein thrombosis from large vein
commonly abovecommonly above
 the knee → Inferior vena cava → Rightthe knee → Inferior vena cava → Right
atrium →atrium →
 Right ventricle → Pulmonary artery → PERight ventricle → Pulmonary artery → PE
 Ventilation perfusion mismatch →Ventilation perfusion mismatch →
HypoxemiaHypoxemia
 ↓↓Venous return → Right heart failure →Venous return → Right heart failure →
ShockShock

7. DiagnosisDiagnosis
 •• Risk stratificationRisk stratification
 •• Clinical examinationClinical examination
 •• Bed side testsBed side tests
 •• Laboratory testsLaboratory tests
 •• Imaging techniquesImaging techniques

8. Risk factorsRisk factors
 •• Alteration of blood flow:Alteration of blood flow:
 –– Prolonged immobilization,Prolonged immobilization,
 –– Obesity,Obesity,
 –– Pregnancy,Pregnancy,
 –– CancerCancer

9.  Factors in blood vessel wall:Factors in blood vessel wall:
a.a. –– Surgery,Surgery,
b.b. –– Catheterisation.Catheterisation.
c.c. –– TraumaTrauma

10. Hypercoagulable states:Hypercoagulable states:
 –– Estrogen containing OCP,Estrogen containing OCP,
 –– Genetic thrombophilia (Factor V LeidenGenetic thrombophilia (Factor V Leiden
deficiency, Protein C anddeficiency, Protein C and
 Protein S deficiency, antithrombinProtein S deficiency, antithrombin
deficiency etc.),deficiency etc.),
 –– Acquired thrombophilia (antiphospholipidAcquired thrombophilia (antiphospholipid
syndrome, nephroticsyndrome, nephrotic
 syndrome, paroxysmal nocturnalsyndrome, paroxysmal nocturnal
hemoglobinuria)hemoglobinuria)

11. Risk stratificationRisk stratification
 Clinical judgmentClinical judgment
 •• Wells score for PEWells score for PE
 •• Modified Geneva score for PEModified Geneva score for PE

12. Wells score for PEWells score for PE

13. Modified Geneva score forModified Geneva score for
PEPE

14. Clinical Presentation:Clinical Presentation:
SymptomsSymptoms
 •• Chest pain: Sharp, pleuritic in nature, noChest pain: Sharp, pleuritic in nature, no
radiation,radiation,
 aggravated by coughing and deep breathaggravated by coughing and deep breath
 •• HaemoptysisHaemoptysis
 •• Shortness of breathShortness of breath
 •• CollapseCollapse
 •• PalpitationsPalpitations
 •• Sudden death: 15% of sudden death dueSudden death: 15% of sudden death due
to PEto PE

15. Clinical Presentation:Clinical Presentation:
SignsSigns
 Dyspnoea, cyanosis, paleDyspnoea, cyanosis, pale
 •• TachypneaTachypnea
 •• TachycardiaTachycardia
 •• HypoxiaHypoxia
 •• HypotensionHypotension
 •• Pulmonary hypertensionPulmonary hypertension

16. Chest examinationChest examination
 •• May be normalMay be normal
 •• Friction rubFriction rub
 •• Features of pleural effusionFeatures of pleural effusion
 •• Raised JVPRaised JVP

17. InvestigationsInvestigations
 •• Bed side tests: ECG, ABGBed side tests: ECG, ABG
 •• Blood tests: D-dimer, FBC,Blood tests: D-dimer, FBC,
Troponin, UECTroponin, UEC
 •• Imaging techniques: Ultrasound/Imaging techniques: Ultrasound/
Doppler scan,Doppler scan,
 Chest xray, CTPA, V/Q scan,Chest xray, CTPA, V/Q scan,
EchocardiogramEchocardiogram

18. ABG findings in PEABG findings in PE
 pH= ↑pH= ↑
 •• PaO2= ↓PaO2= ↓
 •• PaCO2= ↓PaCO2= ↓
 •• HCO3= NormalHCO3= Normal
 •• Aa gradient= LargeAa gradient= Large
 Aa gradient= PAO2- PaO2Aa gradient= PAO2- PaO2

19. Chest xrayChest xray
 Mostly normal findingsMostly normal findings
 •• Done to exclude other pathologyDone to exclude other pathology
 •• Plural effusionPlural effusion
•• Specific signs:Specific signs:
 - Hampton’s hump- Hampton’s hump
 - Westermark sign- Westermark sign

20.  Hampton's humpHampton's hump, also called , also called HamptonHampton
humphump, is a radiologic sign which consists, is a radiologic sign which consists
of a shallow wedge-shaped opacity in theof a shallow wedge-shaped opacity in the
periphery of the lung with its base againstperiphery of the lung with its base against
the pleural surface. the pleural surface.

21. Hampton’s humpHampton’s hump

22. Westermark signWestermark sign
 the the Westermark signWestermark sign is a is a signsign that that
represents a focus of represents a focus of oligemiaoligemia
(hypovolemia) (leading to collapse of (hypovolemia) (leading to collapse of
vessel) seen distal to a vessel) seen distal to a
pulmonary embolismpulmonary embolism (PE) (PE)

23. Westermark signWestermark sign

24. ECG findings in PEECG findings in PE
 •• Normal sinus rhythmNormal sinus rhythm
 •• Sinus tachycardiaSinus tachycardia
 •• Tall peaked T waves in V1- V4Tall peaked T waves in V1- V4
 •• S1Q3T3 pattern: Not specific. Can beS1Q3T3 pattern: Not specific. Can be
seen in any Cor pulmonale syndromeseen in any Cor pulmonale syndrome
 •• RBBBRBBB

25. S1Q3T3 pattern ECGS1Q3T3 pattern ECG

26. D-dimer in PED-dimer in PE
 D-dimer is a type of Fibrin degradationD-dimer is a type of Fibrin degradation
productproduct
 •• Can be raised due to a number ofCan be raised due to a number of
reasonsreasons
 •• Negative D-dimer rules out PE/DVT inNegative D-dimer rules out PE/DVT in
98% cases98% cases
 •• False positive D-dimer:False positive D-dimer: infection,infection,
pregnancy, renalpregnancy, renal failure, post-operativefailure, post-operative

27. Echocardiogram in PEEchocardiogram in PE

28. CTPACTPA
 Indications:Indications:
 - Suspected PE- Suspected PE
 Contra-indications:Contra-indications:
 - Renal failure- Renal failure
 - Pregnancy- Pregnancy
 - Allergy to radio-contrast- Allergy to radio-contrast
 Procedure:Procedure:
 - Radioactive iodine administered IV- Radioactive iodine administered IV
 - CT scan performed- CT scan performed

30. Ventilation-perfusion scanVentilation-perfusion scan
 Indications:Indications:
 - Renal failure- Renal failure
 - Pregnancy- Pregnancy
 Procedure:Procedure:
 - Ventilation scan with Xenon inhalation- Ventilation scan with Xenon inhalation
 - Perfusion scan with Tc99m labelled radioactive- Perfusion scan with Tc99m labelled radioactive
dye infusiondye infusion
 - Scan V/Q- Scan V/Q
 - Result: unmatched V/Q- Result: unmatched V/Q

32. Ventilation-perfusion scanVentilation-perfusion scan

34. Pulmonary angiogramPulmonary angiogram
 Gold standard test for PEGold standard test for PE
•• Procedure:Procedure:
 –– Catheter inserted to right ventricleCatheter inserted to right ventricle
 –– Radio opaque dye injectedRadio opaque dye injected
 –– Imaging technique used to identify theImaging technique used to identify the
clotclot

35. Treatment optionsTreatment options
 Symptomatic treatment:Symptomatic treatment:
 –– ABCD approachABCD approach
 –– OxygenOxygen
 –– AnalgesiaAnalgesia
 •• Anticoagulation:Anticoagulation:
 –– IV HeparinIV Heparin
 –– S/C LMWH eg Enoxaparine, DalteparineS/C LMWH eg Enoxaparine, Dalteparine
 –– Oral WarfarinOral Warfarin
 •• IVC filter: If there is contra-indications forIVC filter: If there is contra-indications for
anti-coagulationanti-coagulation
 •• Thrombolysis: tPA eg Alteplase, TenectaplaseThrombolysis: tPA eg Alteplase, Tenectaplase
 •• Surgical procedures: Pulmonary embolectomySurgical procedures: Pulmonary embolectomy

36. Treatment optionsTreatment options
 Massive PE:Massive PE:
Thrombolysis/embolectomyThrombolysis/embolectomy
 •• Sub-massive PE: StronglySub-massive PE: Strongly
considerconsider
 thrombolysis/embolectomy but need tothrombolysis/embolectomy but need to
balance risk of bleedingbalance risk of bleeding
 •• Non-massive PE: AnticoagulationNon-massive PE: Anticoagulation

38. ThrombolysisThrombolysis
 Indications:Indications:
 –– Massive PEMassive PE
 –– Sub-massive PE where risk of bleeding lowSub-massive PE where risk of bleeding low
 •• Contraindications:Contraindications:
 –– Bleeding, recent stroke, HI, current GI bleeding,Bleeding, recent stroke, HI, current GI bleeding,
 bleeding PUD, surgery within 7 daybleeding PUD, surgery within 7 day

39. Drugs:Drugs:
Lytic agent Dose regimen
Streptokinase Loading dose:250000UIV
Continuous infusion:100000 U/h For
24hrs
Uroklinase Loading dose:2000U/Ib IV over 10min
Continuous infusion :2000 U/Ib/H for
12-24h
Alteplase (Tpa) Loading dose:None
Continous infusion :100mg over 2h
Reteplase 1.Bolus: 10U IV
2.Bolus :10U IV after 30min

40. AnticoagulationAnticoagulation
 IV Heparin:IV Heparin:
80 units/kg bolus followed by 18 units/kg infusion80 units/kg bolus followed by 18 units/kg infusion
 •• Monitor APTT 60-90 secMonitor APTT 60-90 sec
•• Side effects:Side effects:
 –– HITS (Heparin induced thrombocytopeniaHITS (Heparin induced thrombocytopenia
syndrome):syndrome):
paradoxical hypercoagulable state leads to clotsparadoxical hypercoagulable state leads to clots
 –– BleedingBleeding

41. AnticoagulationAnticoagulation
 Low molecular weight Heparin (LMWH)Low molecular weight Heparin (LMWH)
 Enoxaprin (Clexane): S/CEnoxaprin (Clexane): S/C
 - 1.5mg/kg/24 hours Or 1mg/kg/12 hours- 1.5mg/kg/24 hours Or 1mg/kg/12 hours
 - 1 mg/kg/24 hours in renal impairment- 1 mg/kg/24 hours in renal impairment
 Duration: 6 to 9 monthsDuration: 6 to 9 months
 Side effect: Low HITSSide effect: Low HITS

42. AnticoagulationAnticoagulation
 Vitamin K antagonistVitamin K antagonist
 •• Warfarin:Warfarin:
5mg PO initial dose5mg PO initial dose
Check regular INR 2-3Check regular INR 2-3
Side effects:Side effects:
 –– BleedingBleeding
 –– Unusual bruisesUnusual bruises

43. IVC filterIVC filter
 Indications:Indications:
 - DVT with massive pulmonary embolus- DVT with massive pulmonary embolus
 - Recurrent PE not treatable with- Recurrent PE not treatable with
anticoagulationanticoagulation
 - Absolute contra-indications for anti-- Absolute contra-indications for anti-
coagulationcoagulation
 - Trauma patients- Trauma patients

45. PE in PregnancyPE in Pregnancy
 All three components of Virchow’s triadAll three components of Virchow’s triad
are affected duringare affected during
 pregnancypregnancy
 •• D-dimer has high negative predictiveD-dimer has high negative predictive
value. False positivevalue. False positive
 result is commonresult is common
 •• V/Q scan is preferred techniqueV/Q scan is preferred technique
 •• CTPA can be done if VQ is inconclusiveCTPA can be done if VQ is inconclusive
 •• Preferred treatment option: LMWHPreferred treatment option: LMWH
 •• Warfarin is contraindicatedWarfarin is contraindicated

46. Prevention of PEPrevention of PE
 Control of obesityControl of obesity
 •• Stop smokingStop smoking
 •• StockingsStockings
 •• Heparin: 5000 units/day IVHeparin: 5000 units/day IV
 •• Enoxaprin: 40 mg/day S/CEnoxaprin: 40 mg/day S/C

47. And finally…And finally…
 PE is often over-diagnosed;PE is often over-diagnosed;
 PE is often under-diagnosed;PE is often under-diagnosed;
 The over- or under-diagnosis of PE resultsThe over- or under-diagnosis of PE results
in increasedin increased
 cost, morbidity, mortality and medico-legalcost, morbidity, mortality and medico-legal
risks.risks.