1) Pulmonary embolism is a blockage in the pulmonary artery or its branches by a blood clot that originated in the veins, causing serious health risks. 2) Risk factors include prolonged bed rest, cancer, smoking, oral contraceptive use, and pregnancy. Symptoms include dyspnea, chest pain, cough, and leg pain. Diagnosis involves tests like CT pulmonary angiography and ventilation-perfusion scanning. 3) Treatment involves oxygen, anticoagulant drugs like heparin and warfarin, and sometimes surgical embolectomy for severe cases. Prevention focuses on leg exercises, early ambulation, and compression stockings.

1. PULMONARY EMBOLISM
Dr.Partha Das
MEM,PGY2
Fortis Hospital, Kolkata
08/04/2016

2. STATISTICS (INDIAN SCENARIO)
• Overall, the annual incidence of PE
ranges between 23 and 69 cases per
100,000 population
• Responsible for up to 15% of all in-
hospital deaths
• Accounts for 20 to 30% of deaths a/w
pregnancy & delivery
• Average case fatality rate within 2 weeks
of Δ of ~ 11 %
• Roughly accounting for at least 100,000
deaths each year
Ref : indianheartjournal.com/ihj09/sep_oct_09/467-469.html

3. DEFINITION
• Refers to the obstruction of the
pulmonary artery or one of its branches
by a thrombus (or thrombi) that
originates somewhere in the venous
system or in the right side of the heart

4. PATHOPHYSIOLOGY
• Embolization
• Impaired gaseous exchange
• Increased pulmonary vascular resistance
• Increased airway resistance
• Decreased pulmonary compliance

5. Contd…
As pulmonary vascular resistance↑, RV
wall tension ↑ & causes further RV dilation
& dysfunction
↓
↑ RV wall tension also compresses the
RCA
↓
↓ subendocardial perfusion & limits
myocardial oxygen supply
↓
Provokes MI → eventually circulatory
collapse & death may ensue
Ref : Harrison’s Principles of Internal Medicine, 18th Ed

6. PREDISPOSING FACTORS
• Malignancy
• Prolonged bed rest
• Long-haul air travel
• Obesity
• COPD
• Systemic arterial HTN
• Smoking
• OCPs
• Pregnancy
• Surgery & trauma
• Post menopausal hormone replacement
• Thrombophilia, AF

7. HEREDITARY FACTORS
• Antithrombin III deficiency
• Protein C deficiency
• Protein S deficiency
• Factor V Leiden
• Plasminogen abnormality
• Fibrinogen abnormality
• Resistance to activated Protein C

8. VIRCHOW’S TRIAD

9. CLINICAL FEATURES
• Dyspnoea (m/c)
• Pleuritic chest pain (sudden & sharp)
• Substernal chest pain
• Cough
• Fever
• Hemoptysis
• Syncope
• Unilateral leg pain (signs of DVT)
• Diaphoresis
• Tachycardia, Tachypnoea
• Hypoxemia (paO2 < 8ommHg)
• S3 or S4 gallop/cardiac murmur

10. Well’s Score For PE
• HR > 100 1.5
• Hemoptysis 1
• H/o previous TE 1.5
• Active malignancy 1
• Signs of DVT 3
Risk for PE
>6 = High risk
2-6 = Moderate risk
<2 = Low risk

11. PE Severity Index (PESI)
Predictors Points
• Age +1 per year
• Male sex +10
• Heart Failure +10
• Chronic Lung disease +10
• Art. O2 sat. <90% +20
• Pulse >110bpm +20
• RR>30/min +20
• T˚<36˚C/96.8˚F +20
• Cancer +30
• SBP<100mmHg +30
• Altered mentation +60

12. Contd…
Score Risk Class
• <65 I
• 66-85 II
• 86-105 III
• 106-125 IV
• >125 V
*Low prognostic risk is defined as ≤ 85
points

13. PE R/O Criteria (PERC)
• Age < 50 years
• HR < 100 bpm
• SpO2 >95% in R/A
• No Hemoptysis
• No exogenous Estrogen use
• No previous TE
• No trauma/Surgery requiring
hospitalization (in 4 weeks)
• No U/L leg swelling

14. DIAGNOSTIC FINDINGS
Chest X Ray
• Radiographic signs include:-
• Fleishner sign: enlarged pulmonary artery
(20%)
• Hampton hump: peripheral wedge of
airspace opacity and implies lung
infarction (20%)
• Westermark's sign: regional oligaemia and
highest positive predictive value (10%)
• Pleural effusion (35%)
• Knuckle sign
Ref : http://radiopaedia.org/articles/pulmonary-embolism

18. Contd…
ECG
• Sinus tachycardia – m/c abnormality
• Complete or incomplete RBBB – a/w ↑
mortality
• RV strain pattern – T wave ↓ in the right
precordial leads (V1-4) ± the inferior leads
• Right axis deviation
• Right atrial enlargement (P pulmonale)
– peaked P wave in lead II > 2.5 mm in
height
• Atrial Tachyarrhythmias – AF, Flutter
• Non specific ST-segment & T wave
changes

20. Contd…
CT Pulmonary Angiography (CTPA)
• filling defects within the pulmonary
vasculature with acute pulmonary emboli
• When observed in the axial plane this has
been described as the polo mint sign

21. Contd…

22. Other Investigations :-
• ECHO - It helps to detect RV
enlargement & RWMA a/w PTE
(McConnell’s sign - hypokinesia of RV
free wall with normal motion of RV apex
is best known indirect sign of PE)
• ABG - ↓ PaO2
• D- Dimer assay
• NT Pro BNP
• V/Q Scan
• Venous USG & Impedence
Plethysmography
• Contrast enhanced Helical CT Lung

23. Diagnostic Approach

24. Management
• Provide O2 by cannula/mask/ventilator –
as indicated
• Elevate head-end of bed
• Elevate lower extremities if DVT is
present
• Morphine to manage pain & anxiety
(avoid in case of severe Hypotension)
• Inj. Heparin 10,000 U i/v bolus followed
by 5000 U i/v 6 hourly charged in 200 ml
N/S
• LMWH (Enoxaparin 1mg/kg BD s/c)
• Dopamine or Dobutamine infusion to treat
hypotension & shock

25. Different LMWH in use
Name Treatment Dose
Enoxaparin
1 mg/kg twice daily
(approved as an inpatient or
outpatient dose), or 1.5
mg/kg once daily (inpatient
dose only)
Dalteparin
100 units/kg twice daily, or
200 units/kg once daily
Tinzaparin
175 units/kg once daily

26. Pulmonary Embolectomy
• Emergency surgical removal of emboli
which are blocking blood circulation &
causing necrosis

27. Vena Cava Filter
• Type of vascular filter, a medical device
that is implanted into the inferior vena
cava to presumably prevent life-
threatening pulmonary emboli

28. Prevention
• Leg exercises (Dorsiflexion of feet)
• Frequent position changes
• Ambulation
• Intermittent pneumatic leg
compression devices
• Anti embolism stockings
• Tab.Warfarin 5mg BD x 3-4 weeks &
then can be tapered to keep INR @
2.5-3

29. REFERENCES
• Tintinalli’s Emergency Medicine e-Book
6th Edition
• Harrison’s Principles of Internal
Medicine 18th Edition
• European Heart Journal, 2014
• Kapoor VK. Venous thromboembolism in
India. The National Medical Journal.
2010;23(4):193-95.
• European Heart Journal Advance
Access published August 29, 2014
• radiopaedia.org/articles/pulmonary-
embolism