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ABDULRAHMAN AL RAFIQ UPDATED MANAGEMENT OF ACUTE PULMONARY EMBOLISM .pdf
- 1. Updated Management of: ABDULRAHMAN AL-RAFIQ TEACHING ASSISTANT – DEPARTMENT OF CARDIOLOGY - SANA’A UNIVERSITY CARDIOLOGY M.D. CANDIDATE ACUTE PULMONARY EMBOLISM
- 5. Agenda ▪ Introduction ▪ Etiology ▪ Clinical Features ▪ Diagnosis ▪ Treatment ▪ Prognosis
- 6. INTRODUCTION
- 8. Susruta (Ayurveda physician and surgeon, 600-1000 B.C) – patient with a “ swollen and painful leg that was difficult to treat” Giovanni Battisa Morgagni, 1761 – recognized clots in pulmonary arteries after sudden death, but didn’t make the connection to DVT
- 10. Discovered PE in 1846 “ The detachment of larger or smaller fragments from the end of a softening thrombus which are carried along the current of blood and driven into remote vessels. This gives rise to the very frequent process on which I have bestowed the name Embolia” RUDOLF VIRCHOW
- 11. Introduction ❑ Thrombi often develop within the leg or pelvic veins, and approximately halfof all DVT embolize to the lungs. ❑ The annual incidence 1 in 1000persons ❑ Almost 20% of patients who are treated for pulmonary embolism dies within 90 days
- 12. ON AVARAGE,ONE AMERICAN DIES OF BLOOD CLOT EVREY 6 MINUTES.
- 13. PE Anatomical Types EMBOLISM OF LESSER DEGREE WITHOUT INFARCTION PULMONARY INFARCTION MASSIVE EMBOLIZATION
- 14. PE Anatomical Types MASSIVE EMBOLIZATION Complete surgical specimen of large pulmonary clot-in-transit
- 15. Massive PE (5%) Submassive PE (25%) PE with Normal BP & RV Function (70%) 5% 25% 70% PE Functional Types
- 16. •Normal BP, Normal RV Function •Good Prognosis with anticoagulation therapy PE with Normal BP & RV Function (70%) N N PE Functional Types
- 17. •Normal BP, RV Dysfunction •Higher risk of complications Submassive PE (25%) N PE Functional Types
- 18. •Hypotension (SBP<90), Cardiogenic shock, Arrest •Respiratory failure Massive PE (5%) PE Functional Types
- 19. • Hypotension (SBP<90), Cardiogenic shock, Arrest • Respiratory failure Massive PE (5%) • Normal BP, RV Dysfunction • Higher risk of complications Submassive PE (25%) • Normal BP, Normal RV Function • Good Prognosis with anticoagulation therapy PE with Normal BP & RV Function (70%) PE Functional Types
- 20. RV Dysfunction
- 21. RV Dysfunction
- 22. ETIOLOGY
- 23. Risk Factors ❑ Hypercoagulability ❑ Malignancy ❑ Immobilization ❑ Trauma ❑ Post- operative ❑ Burns ❑ Infections (COVID-19) ❑ Excess estrogen
- 24. Post- operative or post- partum Phlegmasia alba dolens (milk leg) Extensive pelvic or abdominal operations Hip operations Coagulation disorders Trauma Malignancy Oral contraceptives Fractures: also soft tissue injury Local disorders; varicositie s,phlebitis Prolonged bed rest Prolonged sitting Heart failure Venous stasis
- 25. Most common sources of pulmonary emboli EIV FV DFV PV PTV SPV Less common sources of pulmonary emboli Rt side of heart Gonadal veins Uterine vein Pelvic V.P. GSV SSV
- 26. Most common sources of pulmonary emboli EIV FV DFV PV PTV SPV Less common sources of pulmonary emboli Rt side of heart Gonadal veins Uterine vein Pelvic V.P. GSV SSV
- 28. Factors that increase a woman’s risk for VTE during pregnancy, childbirth, and after delivery
- 30. in
- 35. Common symptoms of pulmonary embolism Fatigue Chest pain Cough Fever Breathlessness Dizziness Diaphoresis Hemoptysis.
- 36. A history of dyspnea, immobilization, recent surgery, active cancer, hemoptysis, previous venous thromboembolism, or syncope was associated with an increased likelihood of pulmonary embolism. Testing for pulmonary embolism should also be considered if a patient appears not to have had a response to treatment for another diagnosed respiratory condition, because initial misdiagnosis is common.
- 37. DVT PE
- 38. CHEST PAIN
- 39. DIAGNOSIS
- 40. Pulmonary Embolism Rule-out Criteria (PERC) D- dimer less useful in ruling out pulmonary embolism because levels are often elevated during illness and after surgery. (PERC) Can safely rule out pulmonary embolism without further diagnostic imaging
- 45. To minimize lung and breast- tissue irradiation in younger patients Ventilation–perfusion single- photon-emission CT (SPECT) is a low-radiation option.
- 48. TREATMENT
- 49. Initial treatment is guided by classification of the pulmonary embolism as Low-risk Intermediate-risk High-risk
- 50. Low-risk PE
- 51. Most patients have low-risk pulmonary embolism, and their care can be managed at home with a direct oral anticoagulant
- 55. LMWH
- 56. LMWH DOAC
- 57. Provoked Persistent risk factor Risk of Bleeding vs Recurrent VTE Patient Preferences
- 58. 3 Months 6 Months Indefinite Unprovoked PE Provoked PE
- 59. Unprovoked PE
- 61. Intermediate risk PE UFH Bleeding Not studied DOAC LMWH
- 62. High-risk PE
- 63. High-risk PE Immediate reperfusion therapy by ruling out contraindications (e.g., brain metastases, bleeding disorders, and recent surgery)
- 67. PROGNOSIS
- 68. ❑pulmonary embolism is not commonly the cause of death ❑Frequently complicates other serious conditions. ❑The true mortality is estimated to be less than 5%