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Pulmonary embolism 21jan21
- 1. Col Bharat Malhotra HOD & Senior Advisor (Medicine)
- 2. PERICARDITIS PERICARDIAL EFFUSION MYOCARDITIS CARDIOMYOPATHY (D/H/R) INFECTIVE ENDOCARDITIS HEART FAILURE • ACUTE • CHRONIC CORONARY • STABLE ANGINA • UA/NSTEMI • STEMI RHD CHD PUL ARTERY EMBOLISM PULMONARY HYPERTENSION ETIOLOGY RISK FACTORS COMPLICATIONS ARTERY • HYPERTENSION • PVD VEIN • DVT AORTIC DISSECTION AORTIC ANEURYSM COARCTATION AORTA CONDUCTION • BRADYCARDIA • TACHYCARDIA
- 3. PLEURAL EFFUSION EMPYEMA PNEUMOTHORAX PNEUMONIA LUNG ABCESS ACUTE RESPIRATORY FAILURE ACUTE RESPIRATORY DISTRESS SYNDROME MECHANICAL VENTILATION PULMONARY EMBOLISM PULMONARY HYPERTENSION VENTILATION HYPOVENTILATION SYNDROMES SLEEP APNEAS MEDIASTINAL ACUTE MEDIASTINITIS CHRONIC MEDIASTINITIS MEDIASTINAL MASS PNEUMOMEDIASTINUM INTERSTITIAL LUNG DISEASE HYPERSENSITIVITY PNEUMONITIS OCCUPATIONAL LUNG DISEASE ASTHMA COPD
- 4. Occlusion or partial occlusion of the pulmonary artery or its branches pulmonary embolism Common cause: An embolized clot from deep vein thrombosis (DVT) involving the lower leg. Less common causes: •Tissue fragments •Fat embolism •Air Embolism •Amniotic fluid Venous thromboembolism (VTE) = Deep Venous Thrombosis (DVT) & Pulmonary Embolism (PE)
- 5. PE is the most common preventable cause of death among hospitalized patients “the Great Masquerader” Diagnosis is difficult because symptoms and signs are nonspecific
- 6. Arterial hypoxemia Pulmonary Hypertension, Right Ventricular (RV) Dysfunction, and RV Microinfarction DVT Embolize Arterial hypoxemia
- 9. Massive PE 5-10% Extensive thrombosis affecting at least half of the pulmonary vasculature Sub-massive PE 20-25% Characterized by RV dysfunction despite normal systemic arterial pressure Low-risk PE 65-75% No RV dysfunction No hypotension
- 10. “the Great Masquerader” Diagnosis is difficult because symptoms and signs are nonspecific Asymptomatic or discovered incidentally Worsening dyspnea Cough, Sputum Hemoptysis Syncope Chest pain – Anginal, Pleuritic Fever, Diaphoresis Cardiogenic shock multiorgan dysfunction Evidence of DVT Normal Exam with sinus tachycardia Sinus Tachycardia Tachypnoea Loud S2, RV dysfunction Crackles, Pleural rub Hypotension, Cardiogenic shock in massive PE
- 11. INTERPRETATION OF TOTAL SCORE: 2-6 points: moderate probability; 7 or more points: high probability
- 12. Wells score for Pulmonary Embolism, ECG, CXR The Great Masquerader – suspect and assess for PE D Dimer Normal No PE High Imaging ECHO Sub-massive/Massive PE (RV dysfunction) CECT Chest CT Venous angiography for PE Do Venous Doppler study lower Limb for DVT Lung Scan (Second line) Normal D Dimer Rule out PE Trop T Pro-BNP
- 13. Plasma D Dimer (ELISA) Useful rule out test Useful rule out test For PE > 500 ng/ml or 0.5 mcg/ml Serum troponin T RV microinfarction Pro- BNP Myocardial stretch Plasma D Dimer (ELISA) Reader
- 14. Frequent - sinus tachycardia Rule out other possibilities
- 15. Frequent - sinus tachycardia RV strain – RBBB, T-wave inversion in leads V1 to V4 S1Q3T3 sign
- 16. A normal or nearly normal chest x-ray often occurs in PE. Other features are less common Rule out other possibilities
- 17. A normal or nearly normal chest x-ray often occurs in PE. Other features are less common Hampton’s Sign Wedge shaped density
- 18. A normal or nearly normal chest x-ray often occurs in PE. Other features are less common Westermark Sign Focal oligemia
- 19. A normal or nearly normal chest x-ray often occurs in PE. Other features are less common Pallas Sign Enlarge Rt Pul Artery
- 20. A normal or nearly normal chest x-ray often occurs in PE. Other features are less common
- 22. Arterial occlusion with failure to enhance the entire lumen due to a large filling defect; the artery may be enlarged compared with adjacent patent vessels
- 23. Ventilation Gaseous radionuclides such as xenon-133, krypton-81m, or technetium-99m DTPA in an aerosol form is inhaled Nuclear Medicine Deptt Perfusion intravenous injection of radioactive technetium macro aggregated albumin (Tc99m-MAA) GAMMA CAMERA GAMMA CAMERA
- 24. High risk of an adverse clinical outcome Hemodynamic instability, RV dysfunction on echocardiography, RV enlargement on chest CT, Elevation of the troponin level due to RV microinfarction Good clinical outcome RV function remains normal ECHO
- 25. 1 2 3
- 26. S/C anticoagulation with (UFH), or (LMWH), or fondaparinux “bridged” 5d to warfarin S/C anticoagulation with (UFH), or (LMWH), or fondaparinux “bridged” 5d novel oral anticoagulant such as dabigatran (a direct thrombin inhibitor) or apixaban (an anti-Xa agent) Oral anticoagulation monotherapy with rivaroxaban (3week) or apixaban (1 week) (both are anti-Xa agents) Loading dose maintenance dose (without S/C anticoagulation) Effective anticoagulation is the foundation for successful treatment of DVT and PE
- 28. Complication Hemorrhage How long to give Initial anticoagulants for 3 months (monitor INR monthly) (Keep INR 2-3) Indefinite – in Unprovoked PE, Recurrent PE, APLA ( keep INR 2-3) Low risk cases if requiring Rx after 3 months Anticoagulants ( INR 1.5-2) Low dose Aspirin in low risk Few Cases
- 29. Replete volume with 500 mL of normal saline (cautious use) Inotropes – dopamine, dobutamine Do ECHO Fibrinolytic therapy - Approved indication Massive PE Controversial indication Sub massive PE 100 mg of recombinant tissue plasminogen activator (tPA) ALTIPLASE prescribed as a continuous peripheral intravenous infusion over 2 h Other option – Tenecteplase Pharmacomechanical Catheter-directed Therapy
- 30. Prevention - because VTE is difficult to detect and poses a profound medical and economic burden Low-dose UFH or LMWH is the most common form of in- hospital prophylaxis once a day. Dabigatran, Rivaroxaban, Apixaban – lower dose • Cancer surgery • Major orthopedic surgeries • Critical Medically ill patients • Mechanical ventilated patients
- 32. The most common cause of a pulmonary embolism (PE) is the result of a blood clot from a deep vein embolizing to the lungs, where it becomes lodged in the pulmonary arteries? TRUE FALSE When a pulmonary embolism occurs, which of the following is seen? A. The patient will have more bradycardia B. The patient will have an increase of PO2 noted on their arterial blood gas C. Ventilation-perfusion mismatch occurs D. Patients usually show no clinical signs/symptoms
- 33. Regarding D-dimer ( which statement is false) A. Is a useful ‘rule out’ test for PE B. Is a useful ‘rule in’ test for PE C. It rarely has useful role in hospitalized patients D. It is a non specific test
- 34. When a pulmonary embolism occurs, we prefer doing following test immediately. Pick the test which is a second line option. A. D dimer B. ABG C. ECHO D. Lung scan
- 35. Treatment of PE is done by all except A. Antibiotics (IV Augmentin) and IV Normal Saline B. Enoxaparin followed by warfarin C. Enoxaparin followed by Apixaban D. Fibrinolytic therapy
- 36. SYMPTOMS DYSNOEA CHEST PAIN HAEMOPTYSIS Tachycardia Tachypnoea Hypotension Cardiogenic shock EVALUATE Wells Criteria D Dimer ECHO DOPPLER LEG CECT CHEST with angiography TREAT Anticoagulants LMWH warfarin LMWH new oral AC Fibrinolytic therapy for massive PE Give Prophylaxis in High risk surgery, Ortho surgery, Cancer, Medical critical ill cases, Mechanically ventilated cases Occlusion or partial occlusion of the pulmonary artery or its branches pulmonary embolism DVT commonest cause – Virchow’s Triad