Pulmoary embolism
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- Pulmonary embolism (PE) occurs when a blood clot lodges in the pulmonary arteries of the lungs, blocking blood flow and impairing respiration. - PE can be provoked by recent risk factors like surgery, pregnancy, or immobilization, which can be removed to reduce recurrence risk. Unprovoked PE occurs without an identifiable transient risk factor and has a higher recurrence risk. - Diagnosis involves assessing risk factors using Wells or Geneva criteria, d-dimer testing, and imaging like CTPA or VQ scan. Treatment depends on severity but typically involves oxygen, anticoagulants for 3 months, and sometimes thrombolysis for critical cases.
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Pulmoary embolism
- 1. Princess Royal Hospital SHREWSBURY AND TELFORD HOSPITALS NHS TRUST Dr AbubakkarRaheel IMT-1Respiratory Medicine 24February2020
- 2. PRINCESS ROYAL HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST • Pulmonary embolism (PE) is a condition in which one or more emboli, usually arising from a thrombus formed in the veins, are lodged in and obstruct the pulmonary arterial system, causing severe respiratory dysfunction. PE Provoked Unprovoked
- 3. PRINCESS ROYAL HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST •Provoked PE is associated with an antecedent (within 3 months) and transient risk factor such as significant immobility, surgery, trauma, pregnancy, concomitant DVT and the use of the combined contraceptive pill or hormone replacement therapy. These risk factors can be removed, thereby reducing the risk of recurrence. •Unprovoked PE (30-50%) occurs in the absence of a transient risk factor. The person may have no identifiable risk factor or a risk factor that is persistent and not easily correctable (such as active cancer or thrombophilia). Because these risk factors cannot be removed, the person is at an increased risk of recurrence.
- 4. PRINCESS ROYAL HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST VTE DVT PE Venous thromboembolism is a term used to encompass both PE and DVT
- 5. PRINCESS ROYAL HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST 3 characteristic presentations of PE Massive PE Sub massive PE Pulmonary Infarction shocked <50% obstruction Mostly stable
- 6. PRINCESS ROYAL HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST PREVALENCE • 3rd most common cardiovascular disease after MI and Stroke (VTE) • 100 - 200 per 100,000 people (VTE) • 60 - 70 per 100,000 people (PE) • 45,594 cases (2013-2014) • 28,000 hospital admissions (2011) • 2300 deaths from PE (2013) • One of the main direct cause of maternal death (UK) • Approx 25,000 people per year die from preventable VTE (UK)
- 7. PRINCESS ROYAL HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
- 8. PRINCESS ROYAL HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST PATHOPHYSIOLOGY Hypoxemia Alveolar collapse Reduced cardiac output Elevation of pulmonary artery pressure Intrapulmonary dead space + impaired gaseous exchange pulmonary artery obstruction Thrombus dislodged
- 9. PRINCESS ROYAL HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST Risk stratification (Revised) GENEVA score Age >65 (+1) • Previous DVT/PE (+3) • Surgery (GA)/lower limb fracture (+2) • Active malignancy (+2) • Unilateral lower limb pain (+3) • Hemoptysis (+2) • Tachycardia (0/+3/+5) • Pain on LL palpation and edema.(+4) Risk Factors – (Revised) Geneva and Wells Score for PE WELLS criteria Clinical features of DVT (+3) Tachycardia 100+ (+1.5) Immobilization/surgery (+1.5) Previous DVT/PE (+1.5) Hemoptysis (+1) Chemotherapy/Ca (+1) Alternative diagnosis less likely than PE (+3)
- 10. PRINCESS ROYAL HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST Symptoms • Dysnea • Tachypnea • Pleuritic chest pain • Features of DVT • Retrosternal chest pain • Cough +/- hemoptysis • Dizziness • Syncope
- 11. PRINCESS ROYAL HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST Signs • Tachycardia • Hypoxia • Pyrexia • Elevated JVP • Gallop rhythm, widely split 2nd HS, TR murmur • hypotension • Cardiogenic shock
- 12. PRINCESS ROYAL HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST Investigations • Routine bloods • Cardiac Troponin • ABG • D dimer [qualitative (bedside) vs quantitative (ELISA) assays] • Chest x ray • ECG • Imaging a) CTPA b) V/Q scanning c) Echo d) Lower limb compression venous ultrasound
- 13. PRINCESS ROYAL HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST Chest x ray Classical peripheral wedge shadow of pulmonary infarction (RCEM learning)
- 14. PRINCESS ROYAL HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST ECG S1QIII TIII pattern (10% only)
- 15. PRINCESS ROYAL HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST CTPA Massive filling defect in main pulmonary vessels (RCEM)
- 16. Management – Primary Care setting Wells score d-dimer CTPA/LMWH Other diagnosis CTPA/LMWH <4 >4 positive negative PRINCESS ROYAL HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
- 17. PRINCESS ROYAL HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST Management – Clinical setting • Oxygen (Target sats 94% above) • Anticoagulant – 3 months (followed by re-assessment of risks and benefits) • Sub-massive without RV strain: LMWH/Fondaparinux followed by NOAC (Apixaban, Rivaroxaban, Dabigatran, Edoxaban) • Sub-massive with RV strain: LMWH followed by alteplase 100mg over 2 hrs IV • Cardiovascular compromise: LMWH followed by thrombolysis (if no contraindications to fibrinolysis) • Active ca and pregnancy: LMWH rather than warfarin • Thrombolysis (alteplase 50mg IV bolus)
- 18. In-Hospital Management Confirmed PE Pharmacological LMWH Fondaparinux Unfractioned Heparin Oral Anticoagulant Mechanical IVC Filter Thrombectomy PRINCESS ROYAL HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
- 19. PRINCESS ROYAL HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST References • National Institute for health and care excellence www.nice.org.uk • British Lung Foundation (2019) Pulmonary embolism statistics. British Lung Foundation • NF (2018) British National Formulary. 76th edn. London: British Medical Association and Royal Pharmaceutical Society. • BTS (2018) BTS Guidelines for the outpatient management of pulmonary embolism. British Thoracic Society. • Royal College of Emergency Medicine. Rcemlearning.co.uk
- 20. PRINCESS ROYAL HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST Questions