Emboli impede the pulmonary circulation both mechanically, and through the release of hormonal substances (serotonin), as well as through other mechanisms (e.g. hypoxaemia) related to the vasospasm they cause.
An elevated titre of antiphospholipid antibodies, especially lupus anticoagulant, is found in around 8.5% of cases of DVT, while being practically nonexistent in the general population.It should be noted that alarge number of patients with positive lupus anticoagulant do not suffer from systemic lupus erythematosus. http://www.hellenicjcardiol.com/archive/full_text/2007/2/2007_2_94.pdf
Medscape. RV S3/S4 gallop.
The Wells Scoring System has a maximum of 12.5 points. If the score is < 4 points, the likelihood of PE is only 8%.
Positive predictive value
May be elevated in MI,post-surgery
ECHO; right ventricular free wall hypokinesis with normal right ventricular apical motion, appears to be specific for PE.
CUS: compression USG
Noradrenaline may be used in severe cases, since by inducing peripheral vasospasm it can increase the pressure in the aorta and the flow to the coronary vessels (improving right heart ischaemia), without affecting right ventricular afterload. Other inotropic drugs (dopamine, dobutamine, isoproterenol and adrenaline) appear to have no place in PE, since they increase O2 consumption without a corresponding improvement in cardiac output
– Age (>60 yrs)
– history of previous VTE
– active cancer
– Prolonged bed rest, such as heart or acute respiratory
failure, obesity, neurological disease
– congenital or acquired thrombophilia
– hormone replacement therapy
– oral contraceptive therapy
– Surgery ( knee surgery, major general surgery)
– Trauma ( hip fracture, spinal cord injury)
– Central venous line
Inherited Risk Factors
• Protein C resistance (Factor V Leiden)
• -Antithrombin III deficiency
• -Protein C deficiency
• -Protein S deficiency
• -Hyperhomocystinemia (? Acquired due to
• Antiphospholipid antibody
PE Wells score
Clinical feature Points
Clinical signs and symptoms of DVT (minimum of leg swelling and pain
with palpation of the deep veins)
An alternative diagnosis less likely than PE 3
Heart rate > 100 beats per minute 1.5
Immobilisation more than 3 days/surgery in previous 4 weeks 1.5
Previous DVT/PE 1.5
Malignancy (on treatment/treated in the past 6 months/palliative) 1
Clinical probability simplified scores
PE likely More than 4
PE unlikely 4 or less
a Adapted with permission from Wells PS et al. (2000) Derivation of a simple clinical model to categorize patients’
probability of pulmonary embolism: increasing the model’s utility with the SimpliRED D-dimer. Thrombosis and
Haemostasis 83: 416–20
esp. helpful in ruling out other causes
– S1Q3T3 (insensitive without clinical symptom)
– inversion of T waves in leads V1–V4
– RAD, right bundle-branch block
• hypoxemia,hypocapnia & resp. Alkalosis ↑A-a
• However,Low PO2 has strong PPV for pts
without respi. diseases
– Fibrin degradation product
– elevated in the presence of thrombus.
- has a negative predictive value.
- a sensitivity for venous thromboembolism of 95-97% and a
specificity of 45%.
- D-dimer < 500 ng/mL using ELISA provides
strong evidence against venous thromboembolism.
• Ischemia modified Albumin (IMA)
• Albumin produced during ischemia
• 93 % sensitive, 75% Specific for PE
combined with scoring systems
• ↑ in MI, ACS
• CT - large, central PE
• PUL. ANGIOGRAPHY
– emboli as small as 1 to 2 mm
• Lung V/Q Scanning
• The perfusion scan defect indicates absent or decreased
blood flow due to PE.
-Ventilation scans improve the specificity of the perfusion scan.
- A high probability scan is defined as two or more segmental
perfusion defects in presence of normal ventilation scan.
Safe exclusion of pulmonary embolism using
the Wells rule and qualitative D-dimer testing
in primary care: prospective cohort study
BMJ 2012; 345 doi• Abstract Geert-Jan Geersing,
• Design Prospective cohort study.
• Setting Primary care across three different regions of the Netherlands (Amsterdam, Maastricht, and
• Participants 598 adults with suspected pulmonary embolism in primary care.
• Interventions Doctors scored patients according to the seven variables of the Wells rule and carried
out a qualitative point of care D-dimer test. All patients were referred to secondary care and
diagnosed according to local protocols. Pulmonary embolism was confirmed or refuted on the basis
of a composite reference standard, including spiral computed tomography and three months’ follow-
• Main outcome measures Diagnostic accuracy (sensitivity and specificity), proportion of patients at
low risk (efficiency), number of missed patients with pulmonary embolism in low risk category (false
negative rate), and the presence of symptomatic venous thromboembolism, based on the composite
reference standard, including events during the follow-up period of three months.
• Results Pulmonary embolism was present in 73 patients (prevalence 12.2%). On the basis of a
threshold Wells score of ≤4 and a negative qualitative D-dimer test result, 272 of 598 patients were
classified as low risk (efficiency 45.5%). Four cases of pulmonary embolism were observed in these
272 patients (false negative rate 1.5%, 95% confidence interval 0.4% to 3.7%). The sensitivity and
specificity of this combined diagnostic approach was 94.5% (86.6% to 98.5%) and 51.0% (46.7% to
• Conclusion A Wells score of ≤4 combined with a negative qualitative D-dimer test result can safely
and efficiently exclude pulmonary embolism in primary care.
• Hemodynamic and respiratory support
– Rest & Oxygen
– Inotropic support +/-
– Mechanical ventilation
– catalyzes the inactivation of thrombin and factor Xa by
– an initial bolus of 80 IU/kg IV, followed by a continuous
infusion of 18 IU/kg/hr IV.
– Rate of the heparin infusion adjusted so that the aPTT is
1.5-2.5 times the control value.
– inactivates factor Xa , minimally prolongs aPTT
– does not require monitoring of its anticoagulant effect
(predictable dose-response relationship)
– lower risk of bleeding complications and
– less protein C and S inhibition, less complement
activation, and a lower risk of osteoporosis
– Enoxaparin- 1 mg/kg SC BD or 1.5 mg/kg OD
started after therapeutic heparinization.
o Oral anticoagulant inhibits reduction of vit K to its
depletion of vit K dependent clotting factors (2,7,9,10)
o difficult dosing, frequent monitoring,
notorious interaction with other drugs/food
• Direct factor Xa inhibitors
• predictable anticoagulation
• no need for dose adjustments and
routine coagulation monitoring
• Rivaroxaban, Apixaban
streptokinase, Urokinase, rTPA
o Massive PE
o Hemod. Unstability, Circulatory shock
• Venous filter (IVC filter)
– contraindications for anticoagulant (active haemorrhage, endangered
haemorrhage following severe brain injury or craniotomy)
– repeated episodes of PE occur despite anticoagulant therapy
• Pulmonary embolectomy
Amniotic fluid embolism
• amniotic fluid, fetal cells, hair, or other debris
enters the mother's blood stream via
the placental bed of the uterus and trigger an
• three prerequisites:
• Ruptured membranes (a term used to define the
rupture of the amniotic sac
• Ruptured uterine or cervical veins
• A pressure gradient from uterus to vein