Pulmonary Embolism as Seen in the ED Edited

8/8/2019 Pulmonary Embolism as Seen in the ED Edited

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Pulmonary Embolism as seen in

the ED

Adapted from source


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This is the real thing

40 y/o male presented to ED with 2 day h/o SOB & leftchest pain radiating to left shoulder and abdomen

Pleuritic pain

Hemoptysis Right ankle fracture/closed reduction/plaster 1 month

ago. Plaster split recently for increased swelling

Previously healthy

Nonsmoker

Family history unremarkable


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Afebrile

Pulse 113

BP 145/91 O2 saturation 98%

Obvious distress

Clear but diminished lungs (no rub)

Plaster on right leg

No pain or swelling in lower extremities


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ECG showed sinus tachycardia

pH 7.42, pCO2 33, pO2 78 on 2 liters O2

WBC 11.8 Troponin I 0.02

D-dimer +

Small left pleural effusion on chest radiograph


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KEY CONCEPTS

Overview of Basic Science

Epidemiology

Typical Presentations in the Emergency Department

Diagnosis Minimizing Risk & Maximizing Resources

Treatment Options

Massive PE Desperate Measures?

Putting it all Together in Practice


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OVERVIEW OF BASIC SCIENCE


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65-90% of PE arise from thrombi in the deepvenous system of the lower extremities

Large thrombi may cause hemodynamiccompromise

Smaller thrombi more likely to cause pleuriticpain

Impaired gas exchange not explained solely onmechanical obstruction

Inflammatory mediators play a big role


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Hypotension is due to decreased cardiacoutput and increased pulmonary vascularresistance

Significant hypotension indicates massive PE

Often results in right ventricular failure and death

Remember Virchows Triad???

Hypercoagulability Stasis

Endothelial injury


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RISK FACTORS


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Risk Factors

Immobilization

Surgery within 3 months

Stroke

History of DVT

Malignancy

Preexisting lung disease

Chronic heart disease Special risks for women

Obesity, >25 cigarettes/day, hypertension, estrogen


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Risk Factors

Idiopathic PE

Factor V Leiden mutation

Up to 40% of cases

Increased factor VIII

6 fold risk/11% western population


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Risk Factors

Economy Class Syndrome

Prolonged travel increases risk of PE/DVT 2 -4 fold

One study using venous doplers revealed DVT

in10%of patients after long haul flights

Compression stockings are helpful in prevention

Consider single prophylactic dose of low

molecular heparin before travel in high riskpatients

Aspirin not shown to be helpful


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EPIDEMIOLOGY


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Epidemiology

PE is the 3rd most common cardiovasculardisease

Leading cause of death in hospitalized patients

over 65

Leading cause of death in women duringpregnancy

Estimated 300, 000 cases/year in the US andEurope

Slightly more common in men than women


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Epidemiology

Mortality rate of 30% without treatment Death primarily due to recurrent PE

Accurate diagnosis and treatment reduces

mortality to 2-8% Right ventricular dysfunction predicts worse

outcome RV dysfunction also predicts risk of recurrent PE/DVT

Common in pregnancy PE/DVT in 1/500 1/2000 pregnancies

More common in postpartum period


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TYPICAL PRESENTATIONS IN THEEMERGENCY DEPARTMENT


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Typical Presentations in the Emergency

Department

Classic symptoms Dyspnea 73%, pleurisy 66%, cough 37%, hemoptysis

13%

Classic signs Tachypnea 70%, rales 51%, tachycardia 30%, abnormal

heart sounds 24%, shock 8%

Fever < 38.9 in 14%

Most patients do not have leg symptoms < 30% of patients have signs and symptoms of DVT

Many patients with DVT do have PE


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DIAGNOSIS MINIMIZING RISK &MAXIMIZING RESOURCES


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Diagnosis Minimizing Risk &

Maximizing Resources

ABG and pulse oximetry have a limited role

Normal PaO2 in 18%

BNP and troponin are insensitive and nonspecific

High levels may predict poor outcome

ECG not very helpful

Radiographic abnormalities common but not specific

Relying on lower extremity venous doppler can lead to

problems Only 29% of patients with PE have clinically evident DVT

? False positive doppler studies


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What about the D-dimer?

D-dimer levels abnormal in 95% of patientswith PE

Normal D-dimer predicts 95% chance of nothaving PE

This only applies to the ELISA test

Unfortunately, normal latex agglutination test mayonly have an 85% chance of not having a PE

It all depends on the clinical probability of PE


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Helical CT scanning

Diagnostic accuracy varies widely based onexperience, technology, and clinical likelihood

of PE

Best accuracy numbers:

90% sensitive

95% specific

Real-life accuracy determined by pre-testprobabilites


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Modified Well Criteria: Clinical Assessment For Pulmonary Embolism

Symptoms of DVT(leg swelling, pain with palpation) 3.0

Other diagnosis less likely than pulmonary embolism 3.0

Heart Rate >100 1.5

Immobilization (>3 days) or surgery in the previous four weeks 1.5

Previous DVT/PE 1.5

Hemoptysis 1.0

Malignancy 1.0

Simplified clinical probability assessment Score

PE likely >4.0

PE unlikely


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TREATMENT OPTIONS


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Treatment Options

Mortality in untreated PE is 30%!!!

Usually due to recurrent PE

Usually within the first few hours of the initial event

Mortality drops to 2-8% with treatment Largely due to prevention of recurrent PE

Effective therapy should be instituted as quickly aspossible

Initial care should focus on stabilization the patient Careful use of fluid

Vasopressor therapy


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Treatment Options

Anticoagulation with heparin

Low molecular weight heparin may be better than

unfractionated heparin in a stable patient

Lower mortality

Fewer recurrences

Less major bleeding

Cost effective

Unfractionated heparin may be better with

massive PE and severe renal failure


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Treatment Options


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Treatment Options

Long term treatment with warfarin

Can be started at the same time as heparin but not

before heparin

Warfarin alone has a 3-fold increase of recurrent PE or DVT

At least 5 days overlap with heparin and warfarin

Usually start with 5 mg warfarin

Target INR 2.0 -3.0

Be careful 3% chance of major hemorrage

Most litigated drug used in emergency medicine in the US


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Treatment Options

Duration of therapyFirst PE

Reversible risk factor

3-6 months

Idiopathic At least 6-12 months

Persistent + D-dimer may predict recurrence

Irreversible risk factor

At least 6-12 months (?indefinitely)

Recurrent PE

Indefinite warfarin


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MASSIVE PE DESPERATEMEASURES?


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Massive PE desperate measures?

Potential indications for thrombolytic therapy inPE

Presence of hypotension related to PE (Massive PE)

Widely accepted use

Presence of severe hypoxemia

Substantial perfusion defect

Right ventricular dysfunction related to PE

Excessive DVT Right ventricular thrombus

? Cardiac arrest related to PE


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Massive PE desperate measures?


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PE is a common problem that is frequently missed

Failure to diagnose PE can result in serious morbidityand mortality

Diagnosis requires careful attention to the patientshistory, knowledge of risk factors, a careful physicalexam, and effective use of a few specialized tests. Dont get fooled by ABG results, blood tests, and ECG

findings, and the chest xray.

Understand when to order a D-dimer and what the resultsidicate

Order the spiral chest CT when appropriate

Start effective anticoagulation as early as possible


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Modified Well Criteria: Clinical Assessment For Pulmonary Embolism

Symptoms of DVT(leg swelling, pain with palpation) 3.0

Other diagnosis less likely than pulmonary embolism 3.0

Heart Rate >100 1.5

Immobilization (>3 days) or surgery in the previous four weeks 1.5

Previous DVT/PE 1.5

Hemoptysis 1.0

Malignancy 1.0

Simplified clinical probability assessment Score

PE likely >4.0

PE unlikely


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Pulmonary Embolism as Seen in the ED Edited

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