A pulmonary embolism occurs when a blood clot or other material occludes the pulmonary artery or its branches. This most commonly results from a deep vein thrombosis in the lower leg that embolizes to the lung. When a PE occurs, it causes ventilation-perfusion mismatching in the lungs. Diagnosis is difficult due to nonspecific symptoms but evaluation involves a Wells criteria assessment, D-dimer testing, echocardiogram, and CT pulmonary angiogram. Treatment consists of anticoagulation with low molecular weight heparin or novel oral anticoagulants. Fibrinolytic therapy may be used in massive PEs. Prevention focuses on prophylaxis in high risk hospitalized patients.

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

8. Virchow’s Triad

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

27. HEPARIN
LMWH
FONDAPARINUX
BIVALIRUDIN
WARFARIN
RIVAROXABAN,
APIXABAN
DABIGATRAN
ALTEPLASE
TENECTIPLASE

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