Acute pulmonary embolism

.
.

(Pulmonary embolism)


Pulmonary embolism
20-30
2-8 1 Pulmonary embolism
(Deep Venous Thrombosis; DVT) lower extremity DVT
Upper extremity
venous catheter2

Trauma

surgery
Atherosclerosis
Venepuncture
Indwelling
catheter
Heart valve
replace
Chemical
irritation

Hypercoagulability

Immobility
Varicose veins
Venous
obstruction
Increased viscosity
Obesity
Atrial fibrillation
Myocardial
infarction

Endothelial injury

Venous stasis

Burn
Malignancy
Sepsis
Pregnancy
Protein C,sS
deficiency
Estrogen therapy

Virchow 's triad

1. (venous stasis)

2. (endothelial injury)

3. (hypercoagulability) ,
antiphospholipid,
Pulmonary Embolism
- thromboembolic events 3
-
oral estrogen venous thromboembolism
oral estrogen Transdermal
oestrogen4
- , thromboembolic complications

pulmonary embolism
caesarean section5
- body mass index (BMI) BMI
25-28.9 ./.. 29 ./.. pulmonary embolism 1.7
3.2 6
- 5,000 .
pulmonary embolism 7
- prolonged immobility, surgery, trauma 75%
venous thromboembolic disease DVT
8 20
pulmonary embolism Idiopathic/unprovoked pulmonary embolism

 1 pulmonary embolism ( 9)

73
>20
70
pleuritis chest pain
66
rales crackle
51

37
>100
30

28
S4
24

26
P2
23

13
DVT
11

10

11
wheeze
9
>38.5 C
7
Angina-like pain
4
wheezing
5
Homans sign
4
Right ventricular lift
4
Pleural friction rub
3
S3
3
Cyanosis
1
1 pulmonary embolism

Modified Wells criteria 3

2 Modified Wells criteria

> 100/
3 1


6
<2 pulmonary embolism
2-6 pulmonary embolism
>6 pulmonary embolism

3
3
1.5
1.5
1
1
1

 D-dimer
D-dimer ( 500 /. (ELISA technique)10)
D-dimer V/Q scan

D-dimer
Clinical suspicious PE

Low

Intermediate or high

D-dimer

Negative

CT pulmonary angiography

Positive

Excluded PE
Normal CT

CT Indeterminate

Definite PE

Not available

Excluded PE

Additional testing:
Pulmonary
angiography,
V/Q scan

Diagnosis PE

V/Q scan

1 Pulmonary embolism
Modified Wells criteria
PERC (Pulmonary Embolism
Rule-out Criteria) Score

pulmonary
embolism


pulmonary embolism
The PERC
Score

3 PERC Score
< 50
< 100/
Oxygen saturation > 94%

 Revised Geneva score pre-test probability

pulmonary embolism Revised Geneva score Modified Wells criteria
Modified Wells criteria
pulmonary embolism Revised Geneva score11
4 Revised Geneva score
> 65

1
Active malignancy

75 -94/
> 95/

Pain on deep palpation of lower limb and unilateral edema

1
3
2
2
2
3
5
3
4

Revised Geneva score

0-3 low probability for acute pulmonary embolism (8%)
4-10 intermediate probability for acute pulmonary embolism (28%)
>11 high probability for acute pulmonary embolism (74%)

D-dimer
D-dimer (93-95% sensitivity)
(50% specificity)12 pretest clinical probability Modified Wells
criteria


DIC
Arterial blood gas
hypoxemia ,respiratory alkalosis,
(Wide A-a O2 gradient)

Cardiac marker
Serum troponin right ventricular ischemia
Microinfarction pulmonary vascular resistance
right ventricular pressure right ventricular ischemia myofibril13
troponin pulmonary embolism

Electrocardiograghy
(Sinus tachycardia)
(Acute cor pulmonale) S1Q3T3 (Prominent S in lead I, inverted Q and
T in lead III), Right bundle branch block, Right axis deviation EKG S1Q3T3
Specificity 100% Sensitivity14%14
1 EKG S1Q3T3 (Prominent S in lead I, inverted Q and T in lead III) ( 15)

Chest X-ray
Cardiac enlargement 27% ,Pleural effusion 23% ,Elevated
hemidiaphragm 20% ,PA enlargement 19%, Atelectasis 18%, Infiltrate 17%,Pulmonary congestion 14%
Oligemia 8%, Pulmonary infarction 5%, Overinflation 5% Normal Chest X-ray 13%16
2 Chest X-ray demonstrating focal
oligemia in the right lung (area between white
arrowheads) and a prominent right descending
pulmonary artery (black arrow) (
17)

 3 Hamptons hump (long arrow), the wedge-shaped

opacity of the peripheral right lung field
(18)

CT pulmonary angiography
non-invasive
Major thrombus pulmonary artery
V/Q scan Pulmonary Angiography

Ventilation-Perfusion scan

segmental (wedge-shaped) perfusion defect

(normal ventilation)

Pulmonary Angiography
Gold standard PE
invasive morbidity rate 3.5% -6%, mortality rate 0.2% - 0.5%
Echocardiography


(RV free wall hypokinesis) (normal RV
apical contractility) McConnells sign acute pulmonary hypertension
PE 19

 (Treatment)
4
4 pulmonary embolism 20
Massive PE : Acute PE (SBP < 90 mmHg 15
inotropic) , , (< 40
)
Submassive PE : Acute PE RV dysfunction myocardial necrosis
RV dysfunction

RV systolic dysfunction echocardiography

RV dilation (4-chamber RV diameter divided by LV diameter > 0.9) CT echocardiography
Elevation of BNP (>90 pg/mL)
Elevation of N-terminal pro-BNP (>500 pg/mL)
Electrocardiographic changes new complete incomplete right bundle-branch block, anteroseptal ST
elevation depression anteroseptal T-wave inversion

Myocardial necrosis
Elevation of troponin I (>0.4 ng/mL)
Elevation of troponin T (>0.1 ng/mL)

Low-risk PE : Acute PE clinical markers Massive

Submassive PE
1. (Anticoagulation)
Unfractionated heparin Low -molecular weight
heparin (LMWH) Unfractionated heparin
65
LMWH

Unfractionated heparin 80/.
18 /./ LMWH enoxaparin 1 ./.
2 Long-term therapy warfarin
5 ./ INR 2-3

 2 pulmonary embolism (21)

2. (Thrombolytic therapy)
Massive PE hemodynamic instability
Recombinant tissue plasminogen activator (t-PA),
Streptokinase Urokinase
3. (Pulmonary embolectomy)
(Surgical embolectomy) (Catheter embolectomy)
unstable

4. (IVC filter)

22

1.

2.

3.

4.

5.
6.

7.

8.

9.

10.

11.

12.

Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism:

clinical outcomes in the International Cooperative Pulmonary
Embolism Registry (ICOPER). Lancet 1999;353(9162):13869.
Moser KM, LeMoine JR. Is embolic risk conditioned by location
of deep venous thrombosis? Ann Intern Med 1981;94(4 pt 1):439
44.
Hansson PO, Welin L, Tibblin G, Eriksson H. Deep vein
thrombosis and pulmonary embolism in the general population.
The Study of Men Born in 1913.Arch Intern Med
1997;157(15):166570.
Canonico M, Plu-Bureau G, Lowe GDO, Scarabin P-Y. Hormone
replacement therapy and risk of venous thromboembolism in
postmenopausal women: systematic review and meta-analysis.
BMJ 2008;336(7655):122731.
Richter ON, Rath W. [Thromboembolic diseases in pregnancy]. Z
Fr Geburtshilfe Neonatol 2007;211(1):17.
Kabrhel C, Varraso R, Goldhaber SZ, Rimm EB, Camargo CA.
Prospective Study of BMI and the Risk of Pulmonary Embolism
in Women. Obesity 2009;17(11):20406.
Lapostolle F, Surget V, Borron SW, et al. Severe Pulmonary
Embolism Associated with Air Travel. N Engl J Med
2001;345(11):77983.
Heit JA, OFallon W, Petterson TM, et al. Relative impact of risk
factors for deep vein thrombosis and pulmonary embolism: A
population-based study. Arch Intern Med 2002;162(11):12458.
Tapson VF. Advances in the Diagnosis and Treatment of Acute
Pulmonary Embolism. F1000 Med Rep [Internet] 2012 [cited
2014 May 6];4. Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357009/
Akpinar EE, Hosgun D, Doganay B, Atac GK, Gulhan M. Should
the cut-off value of D-dimer be elevated to exclude pulmonary
embolism in acute exacerbation of COPD? J Thorac Dis
2013;5(4):4304.
Calisir C, Yavas US, Ozkan IR, et al. Performance of the Wells
and Revised Geneva scores for predicting pulmonary embolism.
Eur J Emerg Med Off J Eur Soc Emerg Med 2009;16(1):4952.
Rathbun SW, Whitsett TL, Vesely SK, Raskob GE. Clinical
utility of D-dimer in patients with suspected pulmonary embolism

13.

14.

15.

16.

17.

18.
19.

20.

21.

22.

and nondiagnostic lung scans or negative CT findings. Chest

2004;125(3):8515.
Kucher N, Goldhaber SZ. Cardiac Biomarkers for Risk
Stratification of Patients With Acute Pulmonary Embolism.
Circulation 2003;108(18):21914.
Firdous N, Nasa P, Bansal A, Juneja D, Kanwar MS, Bera ML.
Comparison of non-invasive diagnostic tests to multi-detector CT
pulmonary angiography for the diagnosis of pulmonary embolism.
J Cardiovasc Dis Res 2013;4(1):403.
Todd K, Simpson CS, Redfearn DP, Abdollah H, Baranchuk A.
ECG for the diagnosis of pulmonary embolism when conventional
imaging cannot be utilized: a case report and review of the
literature. Indian Pacing Electrophysiol J 2009;9(5):26875.
Elliott CG, Goldhaber SZ, Visani L, DeRosa M. Chest
radiographs in acute pulmonary embolism*: Results from the
international cooperative pulmonary embolism registry. CHEST J
2000;118(1):338.
Sreenivasan S, Bennett S, Parfitt VJ. Westermarks and Pallas
Signs in Acute Pulmonary Embolism. Circulation
2007;115(8):e211e211.
Lo C-H, Tang S-E. Hamptons Hump: Am J Med Sci 2014;:1.
Torbicki A. Echocardiographic diagnosis of pulmonary embolism:
a rise and fall of McConnell sign? Eur J Echocardiogr
2005;6(1):23.
Jaff MR, McMurtry MS, Archer SL, et al. Management of
massive and submassive pulmonary embolism, iliofemoral deep
vein thrombosis, and chronic thromboembolic pulmonary
hypertension: a scientific statement from the American Heart
Association. Circulation 2011;123(16):1788830.
Fengler BT, Brady WJ. Fibrinolytic therapy in pulmonary
embolism: an evidence-based treatment algorithm. Am J Emerg
Med 2009;27(1):8495.
Group TPS. Eight-Year Follow-Up of Patients With Permanent
Vena Cava Filters in the Prevention of Pulmonary Embolism The
PREPIC (Prvention du Risque dEmbolie Pulmonaire par
Interruption Cave) Randomized Study. Circulation
2005;112(3):41622.