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Pulmonary emoblism by dr yaser
1. Case presentation
Dr. Yaser Mufti
MD Cardiology Trainee
1/1
7/18/2012
2. CASE STUDY
A 25 years old young female presented to emergency
complaining of Severe shortness of breath that
began abruptly when went for toilet.
Associated symptoms included diaphoresis,
palpitation
One weak back, prior to this event, Patient had
NVD at Home. After 3 days of NVD she has mild
SOB, unnoticed.
7/18/2012 2/66
3. Past history
She has no significant past medical history except NVD at home
wk back
Treatment history
No specific medication usage history
Family history
No family history could be elicited regarding DVT or phelbitits
Personal history
No history of any addiction /drug allergy
7/18/2012 3
4. General examination
Her BP at was 80/60mmHg , temp N
HR 147 BPM
RR 40 PM ,oxygen saturation of 90 %
She was pale , diaphoretic, and unable to speak full
sentence
Her JVP was not recorded
7/18/2012 4
5. Systemic examination
Cardiac exam shows tachy cardia, a fixed wide split of
the second heart sound
Pulmonary exam non specific, NBVB
Abd: soft, no liver or spleen palpable
Her extremities were cold with Weak peripheral
pulses.
Rest of examination normal
7/18/2012 5
6. Differential Diagnosis
Pulmonary Embolism
Congestive heart failure Post Partum
Cardiomyopathy
Myocarditis
ATN due to PPH
7/18/2012 6
7. sinus tachycardia at a rate of 147 BPM,
ECG Right Axis deviation 90+
ST , T wave changes
7/18/2012 7
8. Her ABG’s
Ph: 7.2, PCO: 30 , PO2 : 171 , K : 3.3 , BE: -13
Her CBC , Hb 8.9 g/dl, ESR , 56mm/hr, TLC 10200, and
platelet count 208000, other is in normal range
D dimer report is send but not collected
7/18/2012 8
10. Echo Findings
Emergency Short Echo: (images not available)
Dilated RV(49 MM) with moderately severe Systolic
dysfunction with good kinesis at RV apex
Normal LV function
TR ++, TVPG 14mmHg
Normal Mitral and AV.
IAS appears intact
7/18/2012 10
11. Management
Oxygen
Heparin 5000 iu bolus iv, 1000 iu /hr
Inotropic suppor (Dobutamine/Dopamine)
Plan.
Ct angio /V/Q scan / Lityic therarpy/ Doppler
Outcomes
Unluckily she couldn’t survive and died after few hours
of admissions
7/18/2012 11
12. Short comings and Analysis
•We don’t have above mentioned tests availabilities to
make confirm diagnosis
•Can we use Lytic therapy in this patient, without
confirming PE is debatable.
• She should be managed in Full ICU facilities, rather to
mange in only emergency ward.
7/18/2012 12
16. PE: A Clinical Challenge
Common: 250,000 cases/year
Mimics many other illnesses
Potentially fatal (15%)
Treatment potentially dangerous
No single reliable diagnostic test
Under- and over-diagnosed
7/18/2012 16
17. Acquired Risk Factors
Advancing age
Arterial disease, including carotid and coronary disease
Personal or family history of VTE
Recent surgery, trauma, or immobility, including stroke
CCF/COPD
Acute infection
Long- air travel
Pregnancy, OCP, HRT
Pacemaker, implantable cardiac defibrillator leads, or
indwelling central venous catheter thromboembolism
Obesity, Metabolic syndrome
Cigarette smoking
Hypertension, Abnormal lipid profile
7/18/2012 17
18. INHERITED RISK FACTORS
Hypercoagulable states Factor V Leiden resulting in
activated protein C resistance
Prothrombin gene mutation 20210
Antithrombin III deficiency
Protein C deficiency
Protein S deficiency
Antiphospholipid antibody syndrome(Acquired)
Hyperhomocystenimia
7/18/2012 18
20. Clinical Classification of PE
Massive PE Systolic BP< 90 mmHg,or Thrombolysis
poor tissue Perfusion Or Or embolectomy
Mulitsystem organ failure Or IVC filter
Plus, Rt.or Lt main Plus anticoagulant
Pulmonary Art.
Thrombus or high clot
burden
Hemodyn. Stable,but mod. Addition of Thrombolysis
Submassive PE To severe RV dysfunction Emblectomy or filters
or enlargement remiain controversial
Small to moderate PE Normal hemodyn Anticoagulation
And normal RV Size and
function
7/18/2012 20
21. Pulmonary Infarction
Often characterized by pleuritic chest pain and
hemoptysis
The embolus usually lodges in the peripheral
pulmonary arterial tree, near the pleura.
Tissue infarction usually occurs 3 to 7 days after
embolism.
Sysmptom often includes fever, leukocytosis, elevated
erythrocyte sedimentation rate, and radiologic
evidence of infarction.
7/18/2012 21
22. Nonthrombotic PE
They include fat, tumor, air, and amniotic fluid
Fat embolism ,Usually after bone fractures.
Air embolus during CV catheter central venous catheter.
Amniotic fluid embolism , is characterized by
respiratory failure, cardiogenic shock, and DIC
IVDU sometimes self-inject hair, talc, and cotton that
contaminate the drug they have acquired. These patients
also have susceptibility to septic PE, which can cause
endocarditis of the TV or PV.
7/18/2012 22
23. Clinical Presentation
The PIOPED study reported the following
incidence of common symptoms of pulmonary
embolism[30] :
• Dyspnea (73%)
• Pleuritic chest pain (66%)
• Cough (37%)
• Hemoptysis (13%) Symptoms
7/18/2012 23
29. Clinical probability of Risk A
Determine probability of PE
Low
Moderate
High
Overall clinical impression
Models/scoring systems
7/18/2012 29
31. Blood tests
Troponin levels
Correlation with ECG and Echo
Increase mortality if positive with Acute P.E
BNP
In Absence of Renal function Marker of RV
dystfunction , Predictor of adverse outcome
7/18/2012 31
32. ABG;s
PE significant Hypoxemia
PIOPED, only 26 % of proven PE had Pao>80mmhg
Therefore normal PaO2 can not rule out PE
However Hypoxia in absence of cardiopulmonary
disease should raise suspicion of PE
7/18/2012 32
33. D-Dimers
It is a fibrin degradation fragment Occurs
Through fibrinolysis
Valuable screening test
High sensitivity; low specificity
Helpful only if Negative
Strong Negative Predictive Value-- Rules out PE
when low probability
Safe, noninvasive
Rapid, inexpensive
7/18/2012 33
34. Electrocardiographic Signs of PE
Sinus tachycardia
Incomplete or complete right bundle branch block
Right-axis deviation
S wave >1.5 mm in I and aVL
T wave inversions in leads III and aVF or in leads V1-V4
S wave in lead I and a Q wave and T wave inversion in
lead III (S1Q3T3)
QRS axis greater than 90 degrees or an indeterminate axis
Atrial fibrillation or atrial flutter
7/18/2012 34
35. Chest Radiography
Useful to R/o other causes
Non specific findings; pleural Effusion, atelectasis,
consolidation
Classic sign
Focal oligemia (Westermark sign) indicates massive
central embolic occlusion.
A peripheral wedge-shaped density above the diaphragm
(Hampton hump) usually indicates pulmonary
infarction.
Subtle abnormalities suggestive of PE include
enlargement of the descending right pulmonary artery.
7/18/2012 35
37. V/Q Lung Scan
2nd line investigation method
Beneficial if having normal xray
Who are dye allergic in CT
Renal failure
Pregnancy
Normal V/Q Sensitivity 99%
Rules out PE
High Prob V/Q Specificity 96%
Rules in PE
But, >60% nondiagnostic
Takes >2 hr to perform
Not available at all times
7/18/2012 37
38. Ultrasound and PE
US +DVT in 30-50% with PE
Positive US—confirms PE
Negative ultrasound
PE less likely, but not excluded
Sequential ultrasound
Persistently negative ultrasound at 1-2 wks
<2% DVT/PE at 6mos
Hull et al. J. Thromb 1996; 3:5-8.
7/18/2012 38
39. Echocardiographic Signs of P.E
Right ventricular enlargement or hypokinesis, especially
free wall hypokinesis, with sparing of the apex (the
McConnell sign)
Interventricular septal flattening and paradoxical
motion toward the left ventricle, resulting in a D-shaped
left ventricle in cross section
Tricuspid regurgitation
Pulmonary hypertension with a tricuspid regurgitant jet
velocity >2.6 m/sec
Loss of respiratory-phasic collapse of the inferior vena
cava with inspiration
Direct visualization of thrombus (more likely with
transesophageal echocardiography)
7/18/2012 39
40. CT Angiogram
Benefits Limitations
Available IV contrast
Direct image Expensive
Alternative Dx Patient
Pelvic/leg veins cooperation
Uncertain
sens/spec
7/18/2012 40
41. CT Angiogram
“CT should not be used alone for
suspected PE, but combining tests
improves accuracy and reduces need for
angiography”
”
7/18/2012 41
47. Thrombophilia evaluation
Why test for hypercoagulability?
May affect intensity/duration of treatment
Family counseling about risks
Identify need for prophylaxis in higher risk
situations
7/18/2012 47
49. Thrombophilia evaluation
Consider testing later
Lupus anticoagulant
Decreased Proteins C & S
Decreased Anti-thrombin III
Increased Factor VIII
7/18/2012 49
50. Summary
Have index of suspicion for PE
Develop clinical probability
Interpret all tests in context of pre-test
probability
Selectively for thrombophilia
Choose therapy based on clinical status
7/18/2012 50
60. Thrombectomy
Surgical or transvenous (catheter)
When thrombolytic unsuccessful or
contraindicated, or
Massive PE
7/18/2012 60
61. Vena Cava Filters
Indications:
Contraindication to anticoagulation
Recurrent PE on anticoagulation
Complications from anticoagulation
Massive PE with poor reserve
Problems with filter thrombosis
7/18/2012 61
62. Predictors of Increased Mortality
Hemodynamic instability
Right ventricular hypokinesis on echocardiogram
Right ventricular enlargement on echocardiogram or
chest CT scan
Right ventricular strain on electrocardiogram
Elevated cardiac biomarkers
7/18/2012 62
63. Take home message
Pe common but overlook
High suspicion to make diagnosis
ABG, d-dimer, CT imp diagnostic tools
Prevention is much more important than treatment
Take home message: for DVT Diagnosis
Combine clinical probability, d-dimer, and
ultrasonography
Take home message: for PE diagnosis
Combine clinical score, d-dimer, and CT
pulmonary angiography
7/18/2012 63