Acute pulmonary embolism (PE) is a serious medical condition with variable and nonspecific symptoms such as dyspnea and pleuritic pain, classified into acute or chronic forms. Diagnosis involves various methods including clinical probability assessments and imaging techniques, while management focuses on supportive care and anticoagulation therapy to reduce mortality. Risk factors include deep vein thrombosis (DVT), recent surgery, and certain chronic conditions, emphasizing the importance of prompt recognition and treatment to improve outcomes.

1. PULMONARY EMBOLISM
PULMONARY EMBOLISM
PREPARED BY:
PREPARED BY:
DR. IBRAHIM AYOUB
DR. IBRAHIM AYOUB
DR. SUHAIL KHOJAH
DR. SUHAIL KHOJAH

2. INTRODUCTION
INTRODUCTION
Acute pulmonary embolism (PE) is a common
Acute pulmonary embolism (PE) is a common
and often fatal disease. Mortality can be reduced
and often fatal disease. Mortality can be reduced
from 30% to up to 2-8% by prompt diagnosis
from 30% to up to 2-8% by prompt diagnosis
and therapy.
and therapy.
Unfortunately, the clinical presentation of PE is
Unfortunately, the clinical presentation of PE is
variable and nonspecific, making accurate
variable and nonspecific, making accurate
diagnosis difficult.
diagnosis difficult.

3. CLASSIFICATION
CLASSIFICATION
PE can be classified as
PE can be classified as acute
acute or
or chronic
chronic
-Patients with acute PE typically develop
-Patients with acute PE typically develop
symptoms and signs immediately after
symptoms and signs immediately after
obstruction of pulmonary vessels.
obstruction of pulmonary vessels.
-In contrast, patients with chronic PE tend to
-In contrast, patients with chronic PE tend to
develop slowly progressive dyspnea over a
develop slowly progressive dyspnea over a
period of years due to pulmonary hypertension.
period of years due to pulmonary hypertension.

4. Acute PE can be further classified as
Acute PE can be further classified as massive
massive or
or submassive
submassive:
:
-Massive PE causes hypotension, defined as:
-Massive PE causes hypotension, defined as:
a systolic blood pressure <90 mmHg
a systolic blood pressure <90 mmHg
or
or
a drop in systolic blood pressure of ≥40 mmHg from
a drop in systolic blood pressure of ≥40 mmHg from
baseline for a period >15 minutes.
baseline for a period >15 minutes.
It should be suspected anytime there is hypotension
It should be suspected anytime there is hypotension
accompanied by an elevated central venous pressure (or
accompanied by an elevated central venous pressure (or
neck vein distension), which is not otherwise explained by
neck vein distension), which is not otherwise explained by
acute myocardial infarction, tension pneumothorax,
acute myocardial infarction, tension pneumothorax,
pericardial tamponade, or a new arrhythmia.
pericardial tamponade, or a new arrhythmia.
-All acute PE not meeting the definition of massive PE are
-All acute PE not meeting the definition of massive PE are
considered submassive PE.
considered submassive PE.

5. RISK FACTORS
RISK FACTORS
PE is a common complication of deep vein thrombosis (DVT),
PE is a common complication of deep vein thrombosis (DVT),
occurring in more than 50% of cases confirmed to have DVT.
occurring in more than 50% of cases confirmed to have DVT.
So, factors that promote the development of DVT also increase the risk
So, factors that promote the development of DVT also increase the risk
for PE. These include:
for PE. These include:
-immobilization
-immobilization
-surgery within the last three months
-surgery within the last three months
-stroke, paresis, paralysis
-stroke, paresis, paralysis
-history of venous thromboembolism
-history of venous thromboembolism
-malignancy
-malignancy
-central venous instrumentation within the last three months
-central venous instrumentation within the last three months
-chronic heart disease.
-chronic heart disease.
-Additional risk factors identified in women include
-Additional risk factors identified in women include
obesity (BMI ≥29 kg/m2)
obesity (BMI ≥29 kg/m2)
heavy cigarette smoking (>25 cigarettes per day)
heavy cigarette smoking (>25 cigarettes per day)
hypertension.
hypertension.

6. SYMPTOMS
SYMPTOMS
The most common symptoms are:
The most common symptoms are:
-dyspnea at rest or with exertion (73%)
-dyspnea at rest or with exertion (73%)
-pleuritic pain (44%)
-pleuritic pain (44%)
-cough (34%)
-cough (34%)
->2-pillow orthopnea (28%)
->2-pillow orthopnea (28%)
-calf or thigh pain (44%)
-calf or thigh pain (44%)
-calf or thigh swelling (41%)
-calf or thigh swelling (41%)
-wheezing (21%).
-wheezing (21%).
*The onset of dyspnea was usually within seconds
*The onset of dyspnea was usually within seconds
(46%) or minutes.
(46%) or minutes.

7. SIGNS
SIGNS
The most common signs are:
The most common signs are:
-tachypnea (54%)
-tachypnea (54%)
-tachycardia (24%)
-tachycardia (24%)
-rales (18%)
-rales (18%)
-decreased breath sounds (17%)
-decreased breath sounds (17%)
-loud P2 (15%)
-loud P2 (15%)
-jugular venous distension (14%)
-jugular venous distension (14%)

8. DIFFERENTIAL DIAGNOSES
DIFFERENTIAL DIAGNOSES
Acute coronary syndrome
Acute coronary syndrome
Tention pneumothorax
Tention pneumothorax
Cardiac tamponade
Cardiac tamponade
Aortic dissection
Aortic dissection
Esophageal disorder
Esophageal disorder

9. INVESTIGATIONS
INVESTIGATIONS
Routine laboratory findings (non-specific):
Routine laboratory findings (non-specific):
-leukocytosis
-leukocytosis
-increased erythrocyte sedimentation rate (ESR)
-increased erythrocyte sedimentation rate (ESR)
-elevated serum LDH or AST (SGOT)
-elevated serum LDH or AST (SGOT)
-normal serum bilirubin
-normal serum bilirubin
ABG:
ABG: usually reveal hypoxemia, hypocapnia, and
usually reveal hypoxemia, hypocapnia, and
respiratory alkalosis.
respiratory alkalosis.
The typical ABG findings are not always seen. As an
The typical ABG findings are not always seen. As an
example, massive PE with hypotension and respiratory
example, massive PE with hypotension and respiratory
collapse can cause hypercapnia and a combined
collapse can cause hypercapnia and a combined
respiratory and metabolic acidosis (the latter due to lactic
respiratory and metabolic acidosis (the latter due to lactic
acidosis). In addition, hypoxemia can be minimal or
acidosis). In addition, hypoxemia can be minimal or
absent.
absent.

10. TROPONIN: Serum troponin I and troponin T are elevated in 30-
TROPONIN: Serum troponin I and troponin T are elevated in 30-
50% of patients who have a moderate to large pulmonary embolism.
50% of patients who have a moderate to large pulmonary embolism.
presumed mechanism is acute right heart overload.
presumed mechanism is acute right heart overload.
ECG: ECG abnormalities are also common in patients without PE,
ECG: ECG abnormalities are also common in patients without PE,
limiting the diagnostic usefulness of the ECG.
limiting the diagnostic usefulness of the ECG.
ECG abnormalities historically considered to be suggestive of PE
ECG abnormalities historically considered to be suggestive of PE
-S1Q3T3 pattern
-S1Q3T3 pattern
-right ventricular strain
-right ventricular strain
-new incomplete right bundle branch block
-new incomplete right bundle branch block
ECG changes are infrequent during acute PE. However, they are
ECG changes are infrequent during acute PE. However, they are
common among patients with massive acute PE and cor pulmonale.
common among patients with massive acute PE and cor pulmonale.
CXR:
CXR:
-Atelectasis (69%)
-Atelectasis (69%)
-Pleural effusion (47%)
-Pleural effusion (47%)
-Normal (12%)
-Normal (12%)

11. V/Q SCAN: Diagnostic accuracy is greatest when the V/Q scan is
V/Q SCAN: Diagnostic accuracy is greatest when the V/Q scan is
combined with clinical probability.
combined with clinical probability.
Ultrasound: used to diagnose DVT which is the most common
Ultrasound: used to diagnose DVT which is the most common
cause of PE.
cause of PE.
D-dimer: have good sensitivity and negative predictive value, but
D-dimer: have good sensitivity and negative predictive value, but
poor specificity and positive predictive value.
poor specificity and positive predictive value.
Angiography: Pulmonary angiography is the definitive diagnostic
Angiography: Pulmonary angiography is the definitive diagnostic
technique or "gold standard" in the diagnosis of acute PE.
technique or "gold standard" in the diagnosis of acute PE.
Spiral CT: spiral (helical) CT scanning with intravenous contrast (ie,
Spiral CT: spiral (helical) CT scanning with intravenous contrast (ie,
CT pulmonary angiography or CT-PA) is being used increasingly as
CT pulmonary angiography or CT-PA) is being used increasingly as
a diagnostic modality for patients with suspected PE.
a diagnostic modality for patients with suspected PE.
Initial reports suggested that 98% of patients with PE were detected
Initial reports suggested that 98% of patients with PE were detected
by CT-PA.
by CT-PA.

12. RECOMMENDED DIAGNOSTIC
RECOMMENDED DIAGNOSTIC
APPROACH
APPROACH
When PE is suspected (eg, in a patient with
When PE is suspected (eg, in a patient with
sudden onset of dyspnea, deterioration of
sudden onset of dyspnea, deterioration of
existing dyspnea, or onset of pleuritic
existing dyspnea, or onset of pleuritic
chest pain without another apparent
chest pain without another apparent
cause), the clinician should determine
cause), the clinician should determine
which diagnostic modalities are available
which diagnostic modalities are available
and how much the hospital is experienced
and how much the hospital is experienced
in performing and interpreting spiral CT
in performing and interpreting spiral CT
(CT-PA)
(CT-PA)

13. When PE is suspected, the modified Wells criteria should be applied to
When PE is suspected, the modified Wells criteria should be applied to
determine if PE is unlikely (score <4) or likely (score >4).
determine if PE is unlikely (score <4) or likely (score >4).
The modified Wells Criteria include the following:
The modified Wells Criteria include the following:
Clinical symptoms of DVT (leg swelling, pain with palpation)
Clinical symptoms of DVT (leg swelling, pain with palpation)
3.0
3.0
Other diagnosis less likely than pulmonary embolism
Other diagnosis less likely than pulmonary embolism
3.0
3.0
Heart rate >100
Heart rate >100
1.5
1.5
Immobilization (3 days) or surgery in the previous four weeks
Immobilization (3 days) or surgery in the previous four weeks
1.5
1.5
Previous DVT/PE
Previous DVT/PE
1.5
1.5
Hemoptysis
Hemoptysis
1.0
1.0
Malignancy
Malignancy
1.0
1.0
Probability
Probability
Score
Score
Traditional clinical probability assessment
Traditional clinical probability assessment
High
High
>6.0
>6.0
Moderate
Moderate
2.0 to 6.0
2.0 to 6.0
Low
Low
<2.0
<2.0
Simplified clinical probability assessment
Simplified clinical probability assessment
PE likely
PE likely
>4.0
>4.0
PE unlikely
PE unlikely
< or = 4.0
< or = 4.0

14. Patients classified as PE unlikely should undergo
Patients classified as PE unlikely should undergo
quantitative D-dimer testing. If the D-dimer level
quantitative D-dimer testing. If the D-dimer level
is <500 ng/mL, the diagnosis of PE can be
is <500 ng/mL, the diagnosis of PE can be
excluded.
excluded.
Patients classified as PE likely and patients
Patients classified as PE likely and patients
classified as PE unlikely who have a D-dimer
classified as PE unlikely who have a D-dimer
level >500 ng/mL should undergo CT-PA. A
level >500 ng/mL should undergo CT-PA. A
positive CT-PA confirms the diagnosis of PE.
positive CT-PA confirms the diagnosis of PE.
Alternatively, a negative CT-PA excludes the
Alternatively, a negative CT-PA excludes the
diagnosis of PE.
diagnosis of PE.

15. Modified wells criteria
Modified wells criteria
PE unlikely PE likely
PE unlikely PE likely
Quantitative D-dimer test
Quantitative D-dimer test
<500 ng/ml >500 ng/ml
<500 ng/ml >500 ng/ml
Exclude PE CT-PA
Exclude PE CT-PA

16. In case you are working in CT inexperienced hospital or the
In case you are working in CT inexperienced hospital or the
patieng can’t undergo CP-PA (e.g. renal insufficiency or
patieng can’t undergo CP-PA (e.g. renal insufficiency or
morbid obecity), a ventilation-perfusion (V/Q) scan is then
morbid obecity), a ventilation-perfusion (V/Q) scan is then
performed, with the following combinations of outcomes
performed, with the following combinations of outcomes
possible:
possible:
-Normal V/Q scan plus any clinical probability excludes PE.
-Normal V/Q scan plus any clinical probability excludes PE.
-Low probability V/Q scan plus low clinical probability
-Low probability V/Q scan plus low clinical probability
excludes PE.
excludes PE.
-High probability V/Q scan plus high clinical probability
-High probability V/Q scan plus high clinical probability
confirms PE.
confirms PE.
Any other combination of V/Q scan result plus clinical
Any other combination of V/Q scan result plus clinical
probability should prompt either a pulmonary angiogram
probability should prompt either a pulmonary angiogram
or serial lower extremity venous ultrasound exams.
or serial lower extremity venous ultrasound exams.
A reasonable alternative approach for patients with a low or
A reasonable alternative approach for patients with a low or
intermediate clinical probability of PE is to obtain a D-
intermediate clinical probability of PE is to obtain a D-
dimer. A negative D-Dimer by the SimpliRed assay
dimer. A negative D-Dimer by the SimpliRed assay
excludes PE.
excludes PE.

17. MANAGEMENT
MANAGEMENT
RESUSCITATION
RESUSCITATION:
:
Respiratory support:
Respiratory support:
-oxygen supplement
-oxygen supplement
-severe hypoxemia or respiratory failure Intubation
-severe hypoxemia or respiratory failure Intubation
Hemodynamic support (If the patient presents with systemic
Hemodynamic support (If the patient presents with systemic
hypotension):
hypotension):
-IVF
-IVF
-if not resolved: -norepinephrine
-if not resolved: -norepinephrine
-dopamine
-dopamine
-combined norepinephrine and dobutamine
-combined norepinephrine and dobutamine

18. ANTICOAGULANT THERAPY:
ANTICOAGULANT THERAPY:
Anticoagulant therapy reduces mortality and is considered primary
Anticoagulant therapy reduces mortality and is considered primary
therapy for PE. The goal of anticoagulation is to decrease mortality
therapy for PE. The goal of anticoagulation is to decrease mortality
by preventing recurrent PE.
by preventing recurrent PE.
For patients in whom there is a high clinical suspicion of PE and no
For patients in whom there is a high clinical suspicion of PE and no
excess risk of bleeding, empiric anticoagulation should be initiated
excess risk of bleeding, empiric anticoagulation should be initiated
immediately and continued during the diagnostic evaluation.
immediately and continued during the diagnostic evaluation.
Heparin:
Heparin:
Dose :loading: 80U/Kg IV
Dose :loading: 80U/Kg IV
:maintenance :18U/Kg/h
:maintenance :18U/Kg/h
T ½ : 90m
T ½ : 90m
Route of administration: IV/SC
Route of administration: IV/SC
Duration :7-10 d
Duration :7-10 d
Reversal :stop heparin
Reversal :stop heparin
protamine sulphate :1U neutralize 100 IU heparin
protamine sulphate :1U neutralize 100 IU heparin
No FFP
No FFP

19. • LMWH:
LMWH:
-Dose :brand dependent
-Dose :brand dependent
-Mechanism of action :anti-X > anti-II
-Mechanism of action :anti-X > anti-II
-Route of administration :IV or S/C
-Route of administration :IV or S/C
-Monitoring : not indicated
-Monitoring : not indicated
-Indication for monitoring : pregnancy ,morbid obesity , sever renal or
-Indication for monitoring : pregnancy ,morbid obesity , sever renal or
liver derangement
liver derangement
-Duration : 7-10 d
-Duration : 7-10 d
-Reversal :stop heparin
-Reversal :stop heparin
protamine sulphate :un-predictable response
protamine sulphate :un-predictable response
Warfarin:
Warfarin:
-Route of administration: P.O
-Route of administration: P.O
-Monitoring :INR
-Monitoring :INR
-Desired target INR:2.5
-Desired target INR:2.5

20. Further management:
Further management:
-Thrombolysis.
-Thrombolysis.
-IVC filter.
-IVC filter.
-Embolectomy
-Embolectomy