This document discusses pulmonary embolism (PE), including an overview, case study, and approach. It provides details on: - Risk factors for PE including venous stasis from bed rest or surgery and alterations in coagulation. - Common signs and symptoms of PE such as shortness of breath, chest pain, and tachycardia. - Diagnostic tools for PE including CT angiogram, D-dimer test, Wells criteria, and Geneva criteria to determine probability. - The case study describes a 65-year-old man presenting with shortness of breath following hip surgery who is found to have signs of deep vein thrombosis, suggesting a provoked PE.

1. PULMONARY EMBOLISM
DEPARTMENT OF INTERNAL MEDICINE
DONE BY DR.KAWTHAR AHMED ALI AHMED KADHEM

2. OVERVIEW
 A pulmonary embolism (PE) is a potentially life-threatening
medical emergency which often presents with very few clinical
signs or symptoms.
 PARTIAL PE / TOTAL PE
 THERE ARE SEVERAL TYPES OF EMBOLI THAT DEPEND ON THE
SITE WHICH IS FORMED IN

3. CASE STUDY
 A 65-year-old man presents to the emergency department with acute onset of shortness of breath of 30
minutes' duration. Initially, he felt faint but did not lose consciousness. He is complaining of left-sided
chest pain that worsens on deep inspiration. He has no history of cardiopulmonary disease. A week ago
he underwent a total left hip replacement and, following discharge, was on bed rest for 3 days due to
poorly controlled pain. He subsequently noticed swelling in his left calf, which is tender on examination.
His vital signs revealed a fever of 38.0°C (100.4°F), heart rate 112 bpm, BP 95/65 mmHg, RR 24-28 and an
O₂ saturation on room air of 91%

4. RISK FACTORS
a) VENOUSE STASIS : (eg, bed rest >48 hours, long-distance auto or air travel, recent hospitalization)
b) ALTERATIONS IN COAGULATION ( eg, malignancy, previous PE/DVT, pregnancy, or protein C deficiency)
c) VASECULAR INJURY (eg, trauma, recent surgery, central lines, IV drug use)
A provoked PE refers
to a PE developing in an
individual who has
recognised risk factors
for PE.
An unprovoked
PE refers to a PE
developing in an
individual with no
known underlying risk
factors.

5. CLINICAL MANIFISTATION
 Shortness of breath (DYSPNEA )
 Pleuritic chest pain: with each breath, the pleura comes into contact with an ischaemic area of the lung.
 Cough
 Haemoptysis: secondary to infarcted lung tissue.
 Dizziness or syncope: due to haemodynamic instability (i.e. right ventricular strain).
SYMPTOMS

6. CLINICAL MANIFISTATION
 Tachypnoea: a respiratory rate of more than 20 breaths per minute.
 Tachycardia: a heart rate of more than 100 beats per minute.
 Hypotension: suggestive of right ventricular strain.
 Evidence of deep vein thrombosis (DVT) such as a red, swollen calf.
 Pleural rub: a squeaking or grating sound caused by ischaemic lung tissue coming in contact with the
pleura.
 Cyanosis: a late sign that indicates a significant drop in blood oxygen levels (SpO2)
Signs

7. (PE) APPROACH
CT-ANGIO :is the accepted diagnostic modality of choice , It is rapid and sensitive for detecting proximal PE
ABG
V/Q scan : this test is infrequently used today except , when specific contraindications to a CTA exist, Although previously favored
for pregnant patients, guidelines now typically recommend CTA in pregnant patients
D-Dimer: fibrin degradation product that circulates in a patient with a dissolving fibrin thrombus. I t is found in the serum within 1
hour and stops circulating after 7 days
ECG: useful t o rule out a primary cardiac etiology , The classic S 1 Q3T3 combination of findings (S wave in lead I, Q wave in lead
III, and T wave inversion in lead III) is present in <20% of patient with confirmed PE. Right-sided heart strain seen as T-wave
inversions in the anterior leads (v1-v4) may be present in massive PE
CXR : evaluating other causes of the symptoms. In PE, CXR is nonspecific and nondiagnostic, with a normal radiograph
DOPPLAR ULTRASOUND : used to diagnose DVT in a patient with a high clinical suspicion of PE and a negative CTA.
 Troponin : to screen for myocardial damage which may be due to acute coronary syndrome or secondary to PE (due to right heart
strain and prolonged tachycardia).


8. RULE OUT CRITERIA

9. WELLS CRITERIA
PE likely :
more than 4
points
Unlikely : 4
points or
less

10. GENEVA CRITETRIA
AGE 65 YO OR ABOVE 1
PREVIOUS DVT OR PE 3
SURGERY OF FRACTURE WITHIN 1
MONTH
2
ACTIVE MALIGNANT CONDITION 2
UNILATERAL LOWER LIMB PAIN 3
HAEMOPTYSIS 2
HR 75-94BPM 3
HR 95 OR MORE 5
PAIN ON DEEP PALPATION OF
LOWER LIMB AND UNILATERAL
EDEMA
4
0-3 LOW PROBABILITY
4-10 INTERMEDIATE
11 OR MORE HIGH

11. PE APPROACH

12. PE APPROACH

13. LETS SLICE THE CAKE INTO SMALL PIECES WE ARE A VERY
HOSPITABLE DOCTORS
RISK FACTORS :
Venous stasis bed rest >48 hours
Vascular injury : recent surgery
PROVOKED PE
P/E :
Tachypnea (> 20/min), Tachycardia ( > 1 00/min)
Lung examination ( clear)
WHATS YOUR NEXT STEP ?