Very quick review on the pulmonary embolism

1. CASE PRESENTATION:
• A 59 years old female , K/C of diabetes, hypertension ,presented to ER
department with complain of sudden onset of shortness of breath ,
palpitations and severe chest pain for 1 day, not relieved by medications,
associated with Fever 99°F.She travelled by Airplane ,just came Pakistan to
meet her Grand children 2 days back. She was on HRT (Estrogens),Her total
abdominal hystrectomy was done 1 year back.There were no such symptoms
since then.
• Her Baseline investigations were done, CBS was normal,TROP I –ve, her ECG
showed sinus Tachycardia without any ST-T changes or T wave inversions.
Chest X ray was Normal.

2. EXAMINATION:
• VITALS:
• BP---90/74 mmHg
• Respiratory rate: 36/min
• Pulse rate: 128 bpm
• Sp02: 82% AT RA
• CVS: S1+S2+0
• RESP: NVB + B/L coarse crepitations at bases
• GCS 12/15
• B/L pedal edema was present / No Raised JVP

3. PLAN OF ACTION….
Diagnosis???
Management??? Initial/long Term
Follow up???

4. PULMONARY EMBOLISM
PRESENTED BY :
SHEEZA SAEED
HOUSE OFFICER, CARDIOLOGY

5. DEFINITION :
• OBSTRUCTION OF PULMONARY ARTERY OR ONE OF ITS
BRANCHES , BY A THROMBUS ( OR THROMBI), ORIGINATES
SOMEWHERE IN THE VENOUS SYSTEM.
• MOSTLY FROM THE LOWER LIMBS (DVT)
• A POTENTIAL CARDIOVASCULAR EMERGENCY
• DIFFERENT FORMS OF EMBOLI: COULD BE A BLOOD CLOT, AIR,
FAT,AMNIOTIC FLUID AND SEPTIC AS WELL

6. EPIDEMIOLOGY:
• Venous thromboembolism clinically presents as DVT or PE is, globally the 3rd
most frequent acute cardiovascular syndrome behind myocardial infarction
and stroke.
• Annual incidence rate for pulmonary embolism ranges from 39-115 per
100,000 population.
• PE may cause < 300,000 deaths per year in US, ranking high among the causes
of cardiovascular mortality.

7. PATHOPHYSIOLOGY....

8. APPROACH TOWARDS PULMONARY EMBOLISM
• History (Determine Risk Factors)
• Clinical assessment and making Diagnosis (Wells criteria/Predictive Value)
• Investigations
• High/Intermediate/Low Risk PE
• Management

9. RISK FACTORS:

11. SIGNS AND SYMPTOMS
• DYSOPNEA
• CHEST PAIN
• COUGH
• HAEMOPTYSIS
• SYNCOPE
• PRE-SYNCOPE
• HYPOXEMIA
• PAIN IN CALF OR THIGH
• HAEMODYNAMIC
INSTABILIT OR SHOCK

12. PREDICTION OF PE?(PRE-TEST PROBABILITY)

15. • INVESTIGATIONS:
CHEST X-RAY
ECG
• RV strain pattern- inversion of t wave in lead v1-v4
• S1Q3T3 Pattern
• Incomplete or complete right bundle branch block
• Sinus tachycardia- in 40% patients
• Atrial arrhythmias/ atrial fibrillation
• Right axis deviation

16. • Sinus tachycardia
• Simultaneous t wave inversions in v1-v4 and inferior leads

21. ECHOCARDIOGRAPHY:

23. PULMONARY EMBOLISM SEVERITY INDEX (PESI SCORE)

25. TREATMENT IN ACUTE PHASE:
• HEMODYNAMICANDRESPIRATORY SUPPORT:
1)Oxygentherapyand ventilation
2) Medical treatment of acuterightventricular failure
• INITIALANTICOAGULATION
1. Parenteral anticoagulation: sub-cutaneous weight adjusted bolus low molecular
weight heparin(LMWH) ,fondaparinux or IV UF heparin
2) NON- Vitamin k antagonists
3) Vitamin K antagonists

26. NON VITAMIN K ANTAGONISTS / VKA:
ORAL ANTICOAGULANTS
• Dabigatron not recommended in patients with CrCL < 30ml/ min
• Edoxaban should be given at a dose of 30 mg once daily in patients with Crcl of 15-50 ml/ min and not
recommended in patients with Crcl <15
• Rivaroxaban and Apixiban are to be used with caution in the patients CrCl 25-29 ml/min and their use
is not recommended in patients with Crcl <15 ml/ min
• When VKAs( WARFARIN) are used, anticoagulation with UFH , LMWH or fondaparinaux should be
contined in parallel with oral anticoagulant for > 5 days and until INR has been 2-3 for 2 consecutive
days.

28. REPERFUSION THERAPY: (THROMBOLYSIS)
• Systemic thrombolysis
• Percutaneous catheter directed treatment
• Surgical Embolectomy
• Vena Caval FILTERS- Prevent clots from reaching pulmonary circulation.

29. INDICATIONS FOR THROMBOLYSIS:
• HEMODYNAMIC IN STABILITY
• HYPOXIA ON 100% OXYGEN
• RV DYSFUNCTION
• GREATEST BENEFIT = WITHIN 48 HOURS
• UN SUCCESSFUL > 36 HOURS
• CAN BE USEFUL IN 6-14 DAYS

31. CONTRAINDICATIONS FOR THROMBOLYTIC THERAPY:

36. Discharge Criteria/Hospitalization

38. IN CANCER PATIENTS:

39. IN PREGNANT WOMEN:

41. FOLLOW UP AFTER ACUTE
PULMONARY EMBOLISM:
AT 3-6 MONTHS

43. TAKE HOME MESSAGE:
• ALWAYS KEEP SUSPICION OF PULMONARY EMBOLISM HIGH IN ACUTE SETTINGS
• THINK OF PE IN ANY PATIENT PRESENTING WITH CHEST PAIN OR SOB SPECIALLY IF
ECG AND CHEST X RAY ARE NORMAL, AND STILL patient IS HYPOXIC
• ITS IMP TO RULE OUT PE IN PT, WITH CHEST PAIN, ELEVATED CARDIAC TROP AND
NORMAL ANGIOGRAPHIC FINDINGS .
• CTPA IS IMAGING OF CHOICE TO DIAGONOSE PE.
• START ANTI-COAGULATION IN high risk and intermediate risk, with ongoing
investigations
• NOACS ARE PREFERRED over VKA for oral long term use.
• NOACS and warfarin are not used in pregnancy .
• THROMBOLYSIS SHOULD BE DONE in all HIGH RISK PE patients , until unless
contraindicated .