This document discusses pulmonary embolism (PE), which occurs when an embolism - usually a blood clot - blocks an artery in the lungs, preventing blood flow and oxygenation. PE is a leading cause of hospital death. Risk factors include deep vein thrombosis, stasis of blood flow, hypercoagulability, and hypertension. Clinically, PE presents with dyspnea, chest pain, cough, and tachycardia. Diagnosis involves assessing probability with Wells criteria and tests like ultrasound, CT scan, V/Q scan, or angiography. Treatment focuses on anticoagulation with heparin or warfarin as well as fibrinolytic therapy for massive PE.

1. PULMONARY EMBOLISM
(PE)
ALOK HRIDAY MISHRA
MD 7A1

2. TOPICS TO COVER
• GENERAL WORDS
• DEFINITION
• EPIDEMIOLOGY
• TYPES
• CONCEPT BOOSTER
• PATHOGENESIS
• CLINICAL FEATURE
• DIAGNOSIS
• TREATMENT

3. GENERAL WORDS
PE is among those Five critical condtion of lung
which is associated with cough and(+- dyspnea)
1. Obstructive lung disease
2. Restrictive lung disease
3. Pulmonary vascular abnormality
4. Infection
5. Malignancy
PE fall under the category of pulmonary
vascular abnormality

4. DEFINITION
The sudden blockage of pulmonary artery or its
branches by an embolus.
Types of embolus:-
1. Air (gas)
2. Viscous fluid (e.g. amniotic fluid)
3. Fat
4. Thrombus
5. Septic embolus
Among these types thrombus is much common that causes PE
This embolus blocks the blood supply to the affected area of
lung parenchyma, thus leads to cough, dyspnea and other
clinical features.
IT COULD BE EVEN FATAL

5. EPIDEMIOLOGY
• Most common preventable cause of death in
hospitalized patients.
• PE is 3rd most common cardiovascular cause of
death. 1st is Ischemic heart disease
2nd is stroke
• 1 out of 10 patients with PE die within the first
hour.
• Death rate of men by PE is 20-30% more than
females

6. TYPES OF PULMONARY EMBOLISM

7. CONCEPT BOOSTER

8. • Thrombus in deep veins is called
DEEP VENOUS THROMBUS (DVT)
• DVT PE
• These deep veins can be from different veins of
lower or even upper extremity, most common by
1. Popliteal vein
2. Femoral veins
• Stasis of blood (varicose veins, comatose patients,
immobile limb)
• Hypercoagubility,(nephrotic syndrome) leads to
release of many coagulant in urine such as protein
C and Protein S as well as Antithrombin III
• Hypertension:- high BP in long run starts to
damage endothelial lining this coould be the
reason of male fatality rate is higher than female

10. • Not only thrombus;
But also,
1. fat embolus ----------> fracture of long bone
2. Air embolus---------- > needle stick injury
3. Amniotic embolus--- > pregnancy
4. Setic embolus --------> infected bolus of
bacterial colony
PATIENT MUST BE TAKEN INTO CONSIDERATION

11. PATHOGENESIS
• Deep veins of lower leg
• Femoral veins
• Thrombus dislodges
• Embolus
• Blocks pulmonary vessels
• Ventilation without perfusion
• V/Q reaches infinity
• V/Q mismatch
• Deadspace physiology
• Decreased O2 in Pulmonary artery
• Hypoxaemia
• Hypoxia
• Compensatory reflexes activated
• Vaso contriction
• Loss of function of type II pneumocyte
• Loss of surfactant
• ATELECTASIS

12. Also as the blood supply to lung decreases
• Ischemia
• Infarction
Pulmonary artery radius decreases due to vasoconstriction
• Increase vascular resistance
• Pulmonary hypertension
• Increase work load on RV
Lung parenchyma is highly distensible,
So you can occlude upto 50% of vessel in lung before the RV begin to suffer.
In case of massive PE,
• Increased pressure on RV
• RV dysfucntion
• RV failure
• NO blood/ less blood pumped in lung
• NO blood/ less blood return back to LA
• Less to no blood in LV
• Sudden ischemia
• DEATH

13. CLINICAL FEATURE
• SYMPTOMS:
a. Dyspnea
b. Chest pain
c. Hemoptysis due to pulmonary hypertension
d. Productive cough
• SIGNS:
a. Tachypnea
b. Tachycardia
c. Respiratory distress

14. DIAGNOSIS
First we check for DVT and then PE
• WELL’s criteria for DVT
• WELL’s criteria for PE
If well’s criteria for DVT yields:-
• Low probability--------------------------------------------- > D-dimer
• Intermediate to High probability ------------------------- > compression
Ultrasound of leg
• High probability for DVT + US show No clot-------------> CT-PA
(non invasive)
• If patient is obese, allergic to contrast or haverenal failure then
V/Q scan (non- invasive)
• Even if PE is not clear then PULMONARY ANGIOGRAPHY (invasive)

15. WELL’s criteria for DVT

16. WELL’s criteria for PE

18. CONCLUSION

19. TREATMENT
Fatality rate is high and time is a crucial factor in saving
person’s life
TREATMENT MUST BE AGGRESSIVE
1. Supportive therapy:-
for everyone
asses vitals and secure ABCs
if hypoxic give ……. O2 supplement
If hypotensive give……IV bolus fluid
If bradycardic give……DOBUTAMINE

20. 2. ANTICOAGULANT THERAPY:
• heparin:-
i. UH (unfractionated heparin)
ii. LMWH
 Enoxaparin
 Dalteparin
 Tinzaparin
• Warfarin
• Others
i. Factors Xa inhibitors (ApiXabar)
ii. Direct thrombin inhibitor
(argatroban)

21. 3. FIBRINOLYTIC THERAPY:-
For hemodynamic unstable patients
(in case of MASSIVE EMBOLUS)
TISSUE PLASMINOGEN INHIBITOR (tpA)
• ALTEPLASE
• RETEPLASE
• TENECTEPLASE
4.SURGERY:-
• THROMBECTOMY
• EMBOLECTOMY
For PE ------------------ > HEPARIN
For massive PE --------> tpA