Pulmonary Embolism

Shirley ooi Summary

Caveats

 PE is not isolated desease of the chest but complication of venous thrombosis

(VTE).
 PE oocurs when there is an obstruction from a thrombus in pulmonary artery
or one of its branch.
 Clinical presentation: complete absence of symptom, to catastrophic sudden
death, can present with non specific symptom.
 The most common symptoms: breathlessness, pleuritic chest pain, and cough.
 PE should be considered in patient with breathlessness or chest pain with
normal ausculatory findings and swalowen of the limb(suggestive DVT)
cont

 Leg DVT is found 70% of patients with PE. PE occurs in 50% of patient with
proximal DVT of the legs( involving popliteal and/or more proximal veins)
 Factors predisposing to PE and DVT are the same
 There are various classification of PE based on
1. Patient physiologic response to embolus
2. Risks Type
3. Anatomical locations
Clinica features

 Asymptomatic in some cases

 Breathlesness
 Chest pain (pleuritic pain)
 Cough
 Haemoptysis
 Low grade fever
 Syncope
 Sudden cardiovascular collapse
Physical examination

 Haemodinamic: low BP with hypoxia may suggest PE

 Normal ausculatory findings
 Unilateral limb swelling suggestive of DVT
Diagnostic approach

 PE should be consider in patient with no clear cause of presenting symptoms

such as breathlessness.
 One can use clinical evaluation and well score or Revised Geneva criteria to
determine pretest probability of PE(low, intermediate or high)
 If pretest probability is deemed to be low, PERC can be applied to rule out PE
without any further investigation.
Investigations

 ECG to help exclude other diagnoses such as AMI or pericarditis:

 Most common: sinus tachycardia and non specific ST-segment and Twave inversion in
anteroseptal and inferior leads (70%)
 Classical S1Q3T3 (only present in massive PE)
 Atrial Fibrilation
 ST segment elevation or depression
 Features of right heart strain
 Twave inversion in V1-V4
 Right axis deviation
 S wave (I and avl)
 P pulmonale
 Complete/incomplete RBBB
cont

 Cardiac enzymes
 D-dimer
 ABG
 Lactate
 Cardiac ultrasound following US features suggest PE:
 RV dilatation with plethoric inferior vena cava
 Paradoxical septal motion towards left ventricle appearing as D-shaped septum
 Mc Connell sign ( right ventricular free wall akinesia with sparing of apex)
 Tricuspid regurgitation
 Direct visualitation of the clot in pulmonaru artery, usually seen on trans esophageal
echo
cont

 Venous compression USG: look for DVT in lower limb

 Chest X-ray to exclude other causes like pneumothorax or pneumonia
 Sign suggest PE
 Hamton Hump
 Fleischner sign
 Westermark sign
 CTPA the primary radiology to confirm PE
 Lung scintigraphy
Hampton hump
Fleischner sign
Wastermark sign
Clasification of PE

 MASIVE PE: high risk PE

 Refer to patient with:
 Cardiac arrest
 Persistent hypotension
 Mortality higher need aggressive treatment
 Submassive: intermediate PE
 This seen in patient without hypotension with any following:
 Myocardial necrosis: elevated troponin I>0.4ng/ml
 Right heart strain
 N-terminal proBNP >600ng/L
 Low risk PE
MANAGEMENT

 Supportive
 Aggressive use iv fluids can be hamrfull
 Vassopressor and inotropic support
 Oxygen and ventilation support (target spo2>90%), RSI ,ust be carefull
 Definitive treatment
 Systemic thrombolytic therapy: rtPA+heparin thrombus resolution much faster
 Initial management: IV unfarctioned heparin 80IU/kg( max8000IU) followed by 18 IU/kg
infusion to minimise clot progression then ateplase (100mg if >65kg, 1,5mg/kg <65+ initial
bolus 10% of total dose over 1 minutes, the 90% remaining of total dose in 2 hour), heparin
should stop during rtPA infusion
 In patient with imminent cardiac arrest, 50mg iv rtPA should be given as bolus dose( total dose
not exceed 1.5mg/kg in patient <65)
 Intervention therapy, surgical therapy
 Submassive PE:
 For most case of PE without haemodinamic compremise, is antycoagulan without
systemic thrombolysis
 LMWH enoxaparin 1mg/kg once, warfarin, non vitamin k antagonist oral
anticoagulants (rivaroxaban or dabigatran)
 Low Risk PE
TENGKYU