An short overview of the diagnostic approach and treatment options for Pulmonary Embolism which is a Medical Emergency. In the USA alone about 600,000 people are diagnosed with Pulmonary Embolism every year. However, this is just the tip of the iceberg as many more people have sudden head due to this notorious condition. This Power Point presentation will give you some idea based on my experience in the Emergency Departments in 3 continents of the world.

1. Management of
Pulmonary Embolism in
Emergency Department
Dr A. Barai
MBBS, MRCS Ed, MSc
Registrar in Emergency Medicine

2. Topics
• Introduction
• Diagnostic approach
• Treatment options
• Special circumstances: Pregnant patient
• Prevention

3. Introduction
• Pulmonary embolism (PE) is a medical emergency
where pulmonary artery or its branches are blocked
with embolic substances most commonly blood clots
• Most cases are not life threatening.
• Incidence: 600,000/year in USA
• Mortality rate: 50,000 to 200,000/yr in US

4. Types of PE
• Massive PE: Acute PE with obstructive shock or SBP
<90 mmHg
• Sub-massive PE: Acute PE without systemic
hypotension (SBP ≥90 mm Hg) but with either RV
dysfunction or myocardial necrosis
• Non-massive or low risk PE: None of the above
severe features.

5. Pathophysiology
Deep vein thrombosis from large vein commonly above
the knee → Inferior vena cava → Right atrium →
Right ventricle → Pulmonary artery → PE
Ventilation perfusion mismatch → Hypoxemia
↓Venous return → Right heart failure → Shock

9. Diagnosis
• Risk stratification
• Clinical examination
• Bed side tests
• Laboratory tests
• Imaging techniques

10. Risk factors
• Alteration of blood flow:
– Prolonged immobilisation,
– Obesity,
– Pregnancy,
– Cancer
• Factors in blood vessel wall:
– Surgery,
– Catheterisation.
– Trauma
• Hypercoagulable states:
– Estrogen containing OCP,
– Genetic thrombophilia (Factor V Leiden deficiency, Protein C and
Protein S deficiency, antithrombin deficiency etc.),
– Acquired thrombophilia (antiphospholipid syndrome, nephrotic
syndrome, paroxysmal nocturnal hemoglobinuria)

11. Risk stratification
• Clinical judgement
• Wells score for PE
• Modified Geneva score for PE

12. Wells score for PE

13. Modified Geneva score for PE

15. Clinical Presentation: Symptoms
• Chest pain: Sharp, pleuritic in nature, no radiation,
aggravated by coughing and deep breath
• Haemoptysis
• Shortness of breath
• Collapse
• Palpitations

16. Clinical Presentation: Signs
• Dyspnoea, cyanosis, pale
• Tachypnea
• Tachycardia
• Hypoxia
• Hypotension
• Pulmonary hypertension

17. Chest examination
• May be normal
• Friction rub
• Features of pleural effusion
• Raised JVP

18. Investigations
• Bed side tests: ECG, ABG
• Blood tests: D-dimer, FBC, Troponin, UEC
• Imaging techniques: Ultrasound/ Doppler scan,
Chest xray, CTPA, V/Q scan, Echocardiogram

19. ABG findings in PE
• pH= ↑
• PaO2= ↓
• PaCO2= ↓
• HCO3= Normal
• Aa gradient= Large
Aa gradient= PAO2- PaO2

20. Chest xray
• Mostly normal findings
• Done to exclude other pathology
• Plural effusion
• Specific signs:
- Hampton’s hump
- Westermark sign

21. Hampton’s hump

22. Westermark sign

23. ECG findings in PE
• Normal sinus rhythm
• Sinus tachycardia
• Tall peaked T waves in V1- V4
• S1Q3T3 pattern: Not specific. Can be seen in any Cor
pulmonale syndrome
• RBBB

24. S1Q3T3 pattern ECG

25. D-dimer in PE
• D-dimer is a type of Fibrin degradation product
• Can be raised due to a number of reasons
• Negative D-dimer rules out PE/DVT in 98% cases
• False positive D-dimer: infection, pregnancy, renal
failure, post-operative

26. Echocardiogram in PE

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

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

33. Pulmonary angiogram
• Gold standard test for PE
• Not practised due to the side effects and high
mortality
• Procedure:
– Catheter inserted to right ventricle
– Radio opaque dye injected
– Imaging technique used to identify the clot

34. Treatment options
• Symptomatic treatment:
– ABCD approach
– Oxygen
– Analgesia
• Anticoagulation:
– IV Heparin
– S/C LMWH eg Enoxaparine, Dalteparine
– Oral Warfarin
• IVC filter: If there is contra-indications for anti-coagulation
• Thrombolysis: tPA eg Alteplase, Tenectaplase
• Surgical procedures: Pulmonary embolectomy

35. Treatment options
• Massive PE: Thrombolysis/embolectomy
• Sub-massive PE: Strongly consider
thrombolysis/embolectomy but need to
balance risk of bleeding
• Non-massive PE: Anticoagulation

37. Thrombolysis
• Indications:
– Massive PE
– Sub-massive PE where risk of bleeding low
• Contraindications:
– Bleeding, recent stroke, HI, current GI bleeding,
bleeding PUD, surgery within 7 day, prolonged
CPR
• Drugs:
– Alteplase 100mg IV: 15mg IV stat followed by
85mg over 2 hours
– Followed by Heparin infusion

38. Anticoagulation
• IV Heparin:
– 80 units/kg bolus followed by
– 18 units/kg infusion
• Monitor APTT 60-90 sec
• Side effects:
– HITS (Heparin induced thrombocytopenia
syndrome): paradoxical hypercoagulable state
leads to clots
– Bleeding

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

40. Anticoagulation
• Vitamin K antagonist
• Warfarin:
– 5mg PO initial dose
– Check regular INR 2-3
• Side effects:
– Bleeding
– Unusual bruises
– Headache

41. IVC filter
Indications:
- DVT with massive pulmonary embolus
- Recurrent PE not treatable with anticoagulation
- Absolute contra-indications for anti-coagulation
- Trauma patients

43. PE in Pregnancy
• All three components of Virchow’s triad are affected during
pregnancy
• D-dimer has high negative predictive value. False positive
result is common
• V/Q scan is preferred technique
• CTPA can be done if VQ is inconclusive
• Preferred treatment option: LMWH
• Warfarin is contraindicated

44. Prevention of PE
• Control of obesity
• Stop smoking
• Stockings
• Heparin: 5000 units/day IV
• Enoxaprin: 40 mg/day S/C

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

46. References
• Agnelli G, Becattini C. Acute pulmonary embolism. N Engl J Med. 2010 Jul 15;363(3):266-74.
doi: 10.1056/NEJMra0907731. Epub 2010 Jun 30
• Bourjeily G, Paidas M, Khalil H, et al. Pulmonary embolism in pregnancy.
Lancet. 2010;375:500-512
• Hofman, M. S.; Beauregard, J. -M.; Barber, T. W. et al.(2011). 68Ga PET/CT Ventilation-
Perfusion Imaging for Pulmonary Embolism: A Pilot Study with Comparison to Conventional
Scintigraphy. Journal of Nuclear Medicine 52 (10): 1513–1519.
• Jaff MR, et al. Management of massive and submassive pulmonary embolism, iliofemoral
deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific
statement from the American Heart Association. Circulation. 2011 Apr 26;123(16):1788-830.
doi: 10.1161/CIR.0b013e318214914f. Epub 2011 Mar 21. Erratum in: Circulation. 2012 Mar
20;125(11):e495. Circulation. 2012 Aug 14;126(7):e104.
• Mattu, A. PE in pregnancy: A complicated diagnosis. Medscape. August 9, 2010 (Online) URL:
http://www.medscape.com/viewarticle/726318
• Pulmonary embolism. Life in the fast lane. (Online).
http://lifeinthefastlane.com/education/ccc/pulmonary-embolism/

47. Thank you!
drbarai@gmail.com