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Pe 2

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Pe 2

  1. 1. Pulmonary Embolism <ul><li>Kevin Jones </li></ul><ul><li>PGY-3, Emergency Medicine </li></ul><ul><li>Arrowhead Regional Medical Center </li></ul><ul><li>July 20, 2011 </li></ul>
  2. 2. Epidemiology <ul><li>2 nd leading cause of sudden, unexpected, nontraumatic death </li></ul><ul><li>650-900,000 PE’s diagnosed each year </li></ul><ul><li>~200,000 deaths/years due to PE </li></ul><ul><li>50% of patients with DVT have perfusion defects on nuclear imaging </li></ul><ul><li>40% of patients with PE have asymptomatic DVT </li></ul>
  3. 3. Symptoms <ul><li>Symptoms </li></ul><ul><ul><li>Dyspnea </li></ul></ul><ul><ul><li>Chest pain </li></ul></ul><ul><ul><li>Others: syncope, seizure-like activity </li></ul></ul><ul><li>Signs </li></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Tachypnea </li></ul></ul><ul><ul><li>Hypoxia </li></ul></ul>
  4. 4. JAMA 2006;295(2):172-213.
  5. 6. Wells Criteria <ul><li>Clinical signs of DVT </li></ul><ul><li>Recent sx or immobilization </li></ul><ul><li>HR >100 bpm </li></ul><ul><li>Previous h/o PE or DVT </li></ul><ul><li>Hemoptysis </li></ul><ul><li>Malignancy </li></ul><ul><li>PE most likely diagnosis </li></ul>Points 3 1.5 1.5 1.5 1 1 3 Wells PS, Ginsberg JS, Anderson DR, et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med. 1998;129:997-1005.
  6. 7. Simplified Revised Geneva Score <ul><li>Age >65 </li></ul><ul><li>Previous history of PE or DVT </li></ul><ul><li>Sx or Fx within 1 month </li></ul><ul><li>Active malignancy </li></ul><ul><li>HR 75-94 </li></ul><ul><li>HR >95 </li></ul><ul><li>Unilateral leg edema </li></ul><ul><li>Unilateral leg pain </li></ul><ul><li>Hemoptysis </li></ul>Points 1 1 1 1 1 2 1 1 1 Risk factors Clinical signs Symptoms Wicki J, Perneger TV, Junod AF, et al. Assessing clinical probability of pulmonary embolism in the emergency ward. Arch Intern Med. 2001;161:92-97.
  7. 9. PERC <ul><li>Age < 50 </li></ul><ul><li>HR < 100 </li></ul><ul><li>SpO2 > 94% </li></ul><ul><li>No unilateral leg swelling </li></ul><ul><li>No hemoptysis </li></ul><ul><li>No recent surgery (<4 weeks) </li></ul><ul><li>No prior PE/DVT </li></ul><ul><li>No oral hormone use </li></ul>Kline JA, Mitchell AM, Kabrhel C, et al. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost. 2004;2:1247-1255.
  8. 11. D-dimer <ul><li>Elevated in several disease processes… </li></ul><ul><li>Different assays have different sensitivities </li></ul><ul><li>PE in low-risk patients with a negative D-dimer… </li></ul><ul><ul><li>Thrombus formation >72 hrs before blood draw (circulating dimer t 1/2 = 8 hrs) </li></ul></ul><ul><ul><li>Subsegmental PE </li></ul></ul>
  9. 12. D-dimer Assays <ul><li>Latex-agglutination assay </li></ul><ul><li>Readily available </li></ul><ul><li>Quick & easy to perform </li></ul><ul><li>Less expensive </li></ul><ul><li>Sensitivity ~80% </li></ul><ul><li>NPV 91% </li></ul><ul><li>ELISA assay </li></ul><ul><li>Technician dependent </li></ul><ul><li>Takes longer </li></ul><ul><li>More expensive </li></ul><ul><li>Sensitivity ~95% </li></ul><ul><li>NPV 99.5% </li></ul>Stein P et al. D-dimer for the Exclusion of Deep Venous Thrombosis and Pulmonary Embolism: A Systematic Review . Ann Intern Med 2004;140:589-602.
  10. 13. Diagnosis <ul><li>CT Pulmonary Angiography </li></ul><ul><li>V/Q scan </li></ul><ul><li>Direct Pulmonary Angiography </li></ul><ul><li>Lower extremity U/S </li></ul><ul><ul><li>Sensitivity for PE <40% </li></ul></ul><ul><ul><li>Consider in renal insufficiency, contrast allergy, pregnant </li></ul></ul>
  11. 14. CT pulmonary Angiography <ul><li>Sensitivity/Specificity ~90% </li></ul><ul><li>CTPA use increased 10-fold from 1998-2006 </li></ul><ul><li>Incidence increased 81% from 1998-2006 (112/100,000) with only 3% mortality reduction </li></ul><ul><ul><li>Increased in-hospital antigcoagulation complications during that same time period </li></ul></ul>Wiener RS et al. Time trends in pulmonary embolism in the United States: Evidence of overdiagnosis. Arch Intern Med 2011 May 9; 171:831. Tapson VF. Acute pulmonary embolism: Underdiagnosed and overdiagnosed. [invited commentary] Arch Intern Med 2011 May 9; 171:837.
  12. 15. Massive vs. Submassive PE <ul><li>Massive PE = Acute PE with… </li></ul><ul><ul><li>Hypotension ( any single SBP <90) </li></ul></ul><ul><ul><li>Pulselessness </li></ul></ul><ul><ul><li>Bradycardia (HR <40) + shock </li></ul></ul><ul><li>Submassive PE = Acute PE without hypotension but signs of RV dysfunction/myocardial necrosis </li></ul>
  13. 17. Treatment <ul><li>Anticoagulation </li></ul><ul><ul><li>Heparin – 80mg/kg IV bolus, then 18mg/kg/hr </li></ul></ul><ul><ul><li>Lovenox – 1mg/kg SC q12h </li></ul></ul><ul><ul><li>Arixtra – 5-10mg SC daily </li></ul></ul><ul><li>Thrombolytics </li></ul><ul><ul><li>Alteplase </li></ul></ul>
  14. 18. Thrombolytics <ul><li>Evidence of circulatory/respiratory insufficiency </li></ul><ul><ul><li>Hypotension (SBP <90) </li></ul></ul><ul><ul><li>Hypoxia (SpO2 <95%) </li></ul></ul><ul><li>Evidence of RV dysfunction </li></ul><ul><ul><li>RV dilation/hypokinesis </li></ul></ul><ul><ul><li>Elevated troponin-I (>0.4) or proBNP (>900) </li></ul></ul><ul><ul><li>EKG changes </li></ul></ul><ul><li>FDA-recommended dose: Alteplase 100mg over 2hrs </li></ul>
  15. 20. Fibrinolysis Contraindications <ul><li>Relative </li></ul><ul><li>Age > 75 </li></ul><ul><li>Current anticoagulation use </li></ul><ul><li>Pregnancy </li></ul><ul><li>Noncompressible vascular punctures </li></ul><ul><li>Traumatic or prolonged CPR >10 min </li></ul><ul><li>Recent surgery/bleeding w/in 2-4 wks </li></ul><ul><li>Poorly controlled HTN >180/110 </li></ul><ul><li>Dementia </li></ul><ul><li>Recent Ischemic CVA > 3 months </li></ul><ul><li>Absolute </li></ul><ul><li>Prior ICH </li></ul><ul><li>Known intracranial CV disease (AVM) </li></ul><ul><li>Malignant intracranial neoplasm </li></ul><ul><li>CVA within 3 months </li></ul><ul><li>Suspected aortic dissection </li></ul><ul><li>Active bleeding </li></ul><ul><li>Recent surgery of spinal cord/brain </li></ul><ul><li>Recent closed-head trauma with brain injury </li></ul>
  16. 21. Interventional Options <ul><li>Catheter embolectomy </li></ul><ul><li>Surgical embolectomy </li></ul><ul><li>Reasonable for… </li></ul><ul><ul><li>Massive PE if still unstable after fibrinolysis </li></ul></ul><ul><ul><li>Massive/Submassive PE if fibrinolysis is contra-indicated or there is evidence of adverse prognosis </li></ul></ul>
  17. 22. No imaging? <ul><li>Aggressive early management if… </li></ul><ul><ul><li>High clinical pre-test probability </li></ul></ul><ul><ul><li>RV dysfunction </li></ul></ul><ul><ul><li>Sustained hypotension (SBP <90 for >15 min or requiring inotropic support, & not clearly due to another cause) </li></ul></ul>
  18. 23. Documentation Pearls <ul><li>Why patient is not high risk for MI, UA, Dissection, PE </li></ul><ul><li>No Risk Factors </li></ul><ul><li>No recent surgeries </li></ul><ul><li>No clinical signs of DVT </li></ul><ul><li>Negative D-dimer or PERC </li></ul>

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