Pulmonary Embolism and

Deep Venous Thrombosis

Report by 蔡壁如 2001/9/24

 DVT vs PE
• DVT :
– Begins in the lower extremities
– Originate in the calf near valve cusps or bifurcuti
– 20 ~ 30% clots popliteal, femoral, iliac
– 10% DVT begins in the thigh
• PE :
– Large emboli lodge at the bifurcation
– Smaller emboli into small arteries
– Lower lobe > upper lobe (特別multiple emboli)
– 10 ~ 20% emboli infarction, usually preexisting
cardiopulmonary disease
一、Risk factors

1. Prior venous thromboembolism

2. Bed rest, congestive heart failure, or inactivity
3. Endothelial damage : lower extremity surgery or
trauma
4. Hypercoagulable states : prothrombin mutation,
antithrombin III deficiency, lupus anticoagulant,
and antiphospholipid antibody
5. Malignancy
二、Clinical manifestations

• Symptoms and signs

• Hemodynamic findings
• Differential diagnosis
Symptoms and sign

DVT : calf pain, edema, venous distension,

and pain on passive dorsiflexion of the foot
PE :
dyspnea, chest pain, and cough. tachypnea,
and tachycardia, mild fever below 39℃
hemotysis, pleuritic pain, pleural rub
syncope, chest pain, and dyspnea, RV
dysfunction eg ; RV heave, JV distension,
TR
Hemodynamic finding

• C.O  or 
• RV diastolic pressure 
• RA pressure 
• PAP 
Differential diagnosis

• Small pulmonary embolism :

pneumothorax, congestive heart failure,
hyperventilation, asthma, myocardial
infarction
• Massive pulmonary embolism : RV
infarction, pericardial tamponade,
venous air embolism
三. Laboratory evaluation (1)
• ECG
– 23% normal in small to medium P.E, 6% normal in massive P.E
• Chest X-ray
– Elevation of hemidiaphragm, atelectasis, effusion, margin toward the
hilum
• Noninvasive studies for DVT
– Color flow doppler (Duplex )
– Impedance plethysmography (IPG) or Venous Occlusive
Plethysmography ( VOP )
• D-dimers
– A level below 500 U/ml high negative predictive valve of 91%
三. Laboratory evaluation(2)

• Lung scintigraphy
– 放射性同位素之閃爍造影術

• Pulmonary angiography
– Definitive diagnostic technique in the disease

• Contrast CT
• MRA
四、Prophylaxis for DVT and PE

• Elastic stockings and sequential

compression boots
• Anticoagulation : if no contraindication
• Subcutaneous heparin : mild to moderate risk
• Screening DVT by venous ultrasound : if
Anticoagulation is contraindication
五、Treatment (1) Heparin

– Dose : bolus 75U/Kg

• Keep 18U/Kg/hr, PTT keep 1.5~ 2.5 times
– Duration : 5 ~ 7 days, warfarin overlap in
5th
– Complication :
• hrmorrhage
• Thrombocytopenia 3 ~ 4%
– Contraindication :
• Bleeding
• Thrombocytopenia
• Maligmant pericarditis
 五、Treatment (2)

• Low Molecular Weight (LMW)

– Prophylaxis
– Subcutaneous injection
五、Treatment (3)
• Oral anticoagulants (Warfarin)
– PT keep 2.5 time
– Duration :
• 6 week course :calf vein thrombosis
• 3 ~ 6 m course : proximal DVT and PE
• Life-long anticoagulation :
– cancer
– antiphospholipid antibody syndrome
五、Treatment (4)
Thrombolytic therapy
• Indication
– Acute massive PE with hemodynamic compromise
• Objective
– Accelerate clot lysis,  PAP, improve RV function, improve survival
• Contraindication
– Bleeding, Surgery or trauma (10天內)
• Choice of thrombolytic agent
• Complication
– Bleeding
– streptokinase : allergic , mild fever, itching, hypotension (10%)
 Thrombolytic agents
Drug FDA approved dose Alternative dose Cost
Streptokinase 250,000U x 20min, 1500,000 U x 1h $ 350
100,000U/h x 24 ~72 hrs

Urokinase 4,400 U/Kg bolus 3,000,000U x 2h $ 2000 ~

4,400 U/Kg/h x 12h 2700

tPA 100mg x 2h 0.6mg/kg x $2,000 ~

3 ~ 15 min 4,200
五、Treatment (5)

• IVC Filters
• Pulmonary embolectomy
– 80% do in the first hour
– Mortality : 57% emergency, 25% semiurgent
Venous Study in SICU (89年)

• Total numbers : 772人次

• DATA :
– Venous Occlusive Plethysmography : 199/24
– Venous Duplex : 573/142