PULMONARY EMBOLISMPULMONARY EMBOLISM

PREPARED BY:PREPARED BY:

DR. IBRAHIM AYOUBDR. IBRAHIM AYOUB

DR. SUHAIL KHOJAHDR. SUHAIL KHOJAH

INTRODUCTIONINTRODUCTION

Acute pulmonary embolism (PE) is a common Acute pulmonary embolism (PE) is a common and often fatal disease. Mortality can be reduced and often fatal disease. Mortality can be reduced from 30% to up to 2-8% by prompt diagnosis from 30% to up to 2-8% by prompt diagnosis and therapy. and therapy.

Unfortunately, the clinical presentation of PE is Unfortunately, the clinical presentation of PE is variable and nonspecific, making accurate variable and nonspecific, making accurate diagnosis difficult.diagnosis difficult.

CLASSIFICATIONCLASSIFICATION

PE can be classified as PE can be classified as acuteacute or or chronicchronic

-Patients with acute PE typically develop -Patients with acute PE typically develop symptoms and signs immediately after symptoms and signs immediately after obstruction of pulmonary vessels.obstruction of pulmonary vessels.

-In contrast, patients with chronic PE tend to -In contrast, patients with chronic PE tend to develop slowly progressive dyspnea over a develop slowly progressive dyspnea over a period of years due to pulmonary hypertension.period of years due to pulmonary hypertension.

Acute PE can be further classified as Acute PE can be further classified as massivemassive or or submassivesubmassive::

-Massive PE causes hypotension, defined as:-Massive PE causes hypotension, defined as: a systolic blood pressure <90 mmHg a systolic blood pressure <90 mmHg

or or a drop in systolic blood pressure of ≥40 mmHg from a drop in systolic blood pressure of ≥40 mmHg from

baseline for a period >15 minutes.baseline for a period >15 minutes.

It should be suspected anytime there is hypotension It should be suspected anytime there is hypotension accompanied by an elevated central venous pressure (or accompanied by an elevated central venous pressure (or neck vein distension), which is not otherwise explained by neck vein distension), which is not otherwise explained by acute myocardial infarction, tension pneumothorax, acute myocardial infarction, tension pneumothorax, pericardial tamponade, or a new arrhythmia. pericardial tamponade, or a new arrhythmia.

-All acute PE not meeting the definition of massive PE are -All acute PE not meeting the definition of massive PE are

considered submassive PE.considered submassive PE.

RISK FACTORSRISK FACTORS

PE is a common complication of deep vein thrombosis (DVT), PE is a common complication of deep vein thrombosis (DVT), occurring in more than 50% of cases confirmed to have DVT.occurring in more than 50% of cases confirmed to have DVT.

So, factors that promote the development of DVT also increase the risk So, factors that promote the development of DVT also increase the risk for PE. These include: for PE. These include:

-immobilization-immobilization-surgery within the last three months-surgery within the last three months-stroke, paresis, paralysis-stroke, paresis, paralysis-history of venous thromboembolism-history of venous thromboembolism-malignancy-malignancy-central venous instrumentation within the last three months-central venous instrumentation within the last three months-chronic heart disease.-chronic heart disease.-Additional risk factors identified in women include-Additional risk factors identified in women include obesity (BMI ≥29 kg/m2)obesity (BMI ≥29 kg/m2) heavy cigarette smoking (>25 cigarettes per day)heavy cigarette smoking (>25 cigarettes per day) hypertension. hypertension.

SYMPTOMSSYMPTOMS

The most common symptoms are:The most common symptoms are:-dyspnea at rest or with exertion (73%)-dyspnea at rest or with exertion (73%)-pleuritic pain (44%)-pleuritic pain (44%)-cough (34%)-cough (34%)->2-pillow orthopnea (28%)->2-pillow orthopnea (28%)-calf or thigh pain (44%)-calf or thigh pain (44%)-calf or thigh swelling (41%)-calf or thigh swelling (41%)-wheezing (21%).-wheezing (21%).*The onset of dyspnea was usually within seconds *The onset of dyspnea was usually within seconds

(46%) or minutes. (46%) or minutes.

SIGNSSIGNS

The most common signs are:The most common signs are:

-tachypnea (54%)-tachypnea (54%)

-tachycardia (24%)-tachycardia (24%)

-rales (18%)-rales (18%)

-decreased breath sounds (17%)-decreased breath sounds (17%)

-loud P2 (15%)-loud P2 (15%)

-jugular venous distension (14%) -jugular venous distension (14%)

DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES

Acute coronary syndromeAcute coronary syndrome

Tention pneumothoraxTention pneumothorax

Cardiac tamponadeCardiac tamponade

Aortic dissectionAortic dissection

Esophageal disorderEsophageal disorder

INVESTIGATIONSINVESTIGATIONSRoutine laboratory findings (non-specific):Routine laboratory findings (non-specific):

-leukocytosis -leukocytosis -increased erythrocyte sedimentation rate (ESR) -increased erythrocyte sedimentation rate (ESR) -elevated serum LDH or AST (SGOT) -elevated serum LDH or AST (SGOT) -normal serum bilirubin -normal serum bilirubin

ABG: ABG: usually reveal hypoxemia, hypocapnia, and usually reveal hypoxemia, hypocapnia, and respiratory alkalosis.respiratory alkalosis.

The typical ABG findings are not always seen. As an The typical ABG findings are not always seen. As an example, massive PE with hypotension and respiratory example, massive PE with hypotension and respiratory collapse can cause hypercapnia and a combined collapse can cause hypercapnia and a combined respiratory and metabolic acidosis (the latter due to lactic respiratory and metabolic acidosis (the latter due to lactic acidosis). In addition, hypoxemia can be minimal or acidosis). In addition, hypoxemia can be minimal or absent.absent.

TROPONIN: Serum troponin I and troponin T are elevated in 30-TROPONIN: Serum troponin I and troponin T are elevated in 30-50% of patients who have a moderate to large pulmonary embolism. 50% of patients who have a moderate to large pulmonary embolism. presumed mechanism is acute right heart overload.presumed mechanism is acute right heart overload.

ECG: ECG abnormalities are also common in patients without PE, ECG: ECG abnormalities are also common in patients without PE, limiting the diagnostic usefulness of the ECG.limiting the diagnostic usefulness of the ECG.

ECG abnormalities historically considered to be suggestive of PE ECG abnormalities historically considered to be suggestive of PE -S1Q3T3 pattern-S1Q3T3 pattern -right ventricular strain-right ventricular strain -new incomplete right bundle branch block-new incomplete right bundle branch block ECG changes are infrequent during acute PE. However, they are ECG changes are infrequent during acute PE. However, they are

common among patients with massive acute PE and cor pulmonale. common among patients with massive acute PE and cor pulmonale.

CXR:CXR: -Atelectasis (69%)-Atelectasis (69%) -Pleural effusion (47%)-Pleural effusion (47%) -Normal (12%) -Normal (12%)

V/Q SCAN: Diagnostic accuracy is greatest when the V/Q scan is V/Q SCAN: Diagnostic accuracy is greatest when the V/Q scan is combined with clinical probability. combined with clinical probability.

Ultrasound: used to diagnose DVT which is the most common Ultrasound: used to diagnose DVT which is the most common cause of PE.cause of PE.

D-dimer: have good sensitivity and negative predictive value, but D-dimer: have good sensitivity and negative predictive value, but poor specificity and positive predictive value.poor specificity and positive predictive value.

Angiography: Pulmonary angiography is the definitive diagnostic Angiography: Pulmonary angiography is the definitive diagnostic technique or "gold standard" in the diagnosis of acute PE.technique or "gold standard" in the diagnosis of acute PE.

Spiral CT: spiral (helical) CT scanning with intravenous contrast (ie, Spiral CT: spiral (helical) CT scanning with intravenous contrast (ie, CT pulmonary angiography or CT-PA) is being used increasingly as CT pulmonary angiography or CT-PA) is being used increasingly as a diagnostic modality for patients with suspected PE.a diagnostic modality for patients with suspected PE.

Initial reports suggested that 98% of patients with PE were detected Initial reports suggested that 98% of patients with PE were detected by CT-PA.by CT-PA.

RECOMMENDED DIAGNOSTIC RECOMMENDED DIAGNOSTIC APPROACHAPPROACH

When PE is suspected (eg, in a patient with When PE is suspected (eg, in a patient with sudden onset of dyspnea, deterioration of sudden onset of dyspnea, deterioration of existing dyspnea, or onset of pleuritic existing dyspnea, or onset of pleuritic chest pain without another apparent chest pain without another apparent cause), the clinician should determine cause), the clinician should determine which diagnostic modalities are available which diagnostic modalities are available and how much the hospital is experienced and how much the hospital is experienced in performing and interpreting spiral CT in performing and interpreting spiral CT (CT-PA) (CT-PA)

When PE is suspected, the modified Wells criteria should be applied to When PE is suspected, the modified Wells criteria should be applied to determine if PE is unlikely (score <4) or likely (score >4). determine if PE is unlikely (score <4) or likely (score >4).

The modified Wells Criteria include the following:The modified Wells Criteria include the following:

Clinical symptoms of DVT (leg swelling, pain with palpation) Clinical symptoms of DVT (leg swelling, pain with palpation) 3.03.0

Other diagnosis less likely than pulmonary embolism Other diagnosis less likely than pulmonary embolism 3.03.0

Heart rate >100 Heart rate >100 1.51.5

Immobilization (3 days) or surgery in the previous four weeks Immobilization (3 days) or surgery in the previous four weeks 1.51.5

Previous DVT/PE Previous DVT/PE 1.51.5

Hemoptysis Hemoptysis 1.01.0

Malignancy Malignancy 1.01.0

ProbabilityProbabilityScoreScore

Traditional clinical probability assessment Traditional clinical probability assessment

HighHigh>6.0>6.0

ModerateModerate2.0 to 6.02.0 to 6.0

LowLow<2.0<2.0

Simplified clinical probability assessment Simplified clinical probability assessment

PE likelyPE likely>4.0>4.0

PE unlikelyPE unlikely< or = 4.0< or = 4.0

Patients classified as PE unlikely should undergo Patients classified as PE unlikely should undergo quantitative D-dimer testing. If the D-dimer level quantitative D-dimer testing. If the D-dimer level is <500 ng/mL, the diagnosis of PE can be is <500 ng/mL, the diagnosis of PE can be excluded.excluded.

Patients classified as PE likely and patients Patients classified as PE likely and patients classified as PE unlikely who have a D-dimer classified as PE unlikely who have a D-dimer level >500 ng/mL should undergo CT-PA. A level >500 ng/mL should undergo CT-PA. A positive CT-PA confirms the diagnosis of PE. positive CT-PA confirms the diagnosis of PE. Alternatively, a negative CT-PA excludes the Alternatively, a negative CT-PA excludes the diagnosis of PE. diagnosis of PE.

Modified wells criteriaModified wells criteria PE unlikely PE likelyPE unlikely PE likely

Quantitative D-dimer test Quantitative D-dimer test

<500 ng/ml >500 ng/ml<500 ng/ml >500 ng/ml

Exclude PE CT-PAExclude PE CT-PA

In case you are working in CT inexperienced hospital or the In case you are working in CT inexperienced hospital or the patieng can’t undergo CP-PA (e.g. renal insufficiency or patieng can’t undergo CP-PA (e.g. renal insufficiency or morbid obecity), a ventilation-perfusion (V/Q) scan is morbid obecity), a ventilation-perfusion (V/Q) scan is then performed, with the following combinations of then performed, with the following combinations of outcomes possible:outcomes possible:

-Normal V/Q scan plus any clinical probability excludes PE. -Normal V/Q scan plus any clinical probability excludes PE. -Low probability V/Q scan plus low clinical probability -Low probability V/Q scan plus low clinical probability

excludes PE. excludes PE. -High probability V/Q scan plus high clinical probability -High probability V/Q scan plus high clinical probability

confirms PE.confirms PE.

Any other combination of V/Q scan result plus clinical Any other combination of V/Q scan result plus clinical probability should prompt either a pulmonary angiogram probability should prompt either a pulmonary angiogram or serial lower extremity venous ultrasound exams.or serial lower extremity venous ultrasound exams.

A reasonable alternative approach for patients with a low or A reasonable alternative approach for patients with a low or intermediate clinical probability of PE is to obtain a D-intermediate clinical probability of PE is to obtain a D-dimer. A negative D-Dimer by the SimpliRed assay dimer. A negative D-Dimer by the SimpliRed assay excludes PE.excludes PE.

MANAGEMENTMANAGEMENT

RESUSCITATIONRESUSCITATION::Respiratory support:Respiratory support:

-oxygen supplement-oxygen supplement-severe hypoxemia or respiratory failure Intubation-severe hypoxemia or respiratory failure Intubation

Hemodynamic support (If the patient presents with systemic Hemodynamic support (If the patient presents with systemic hypotension):hypotension):

-IVF-IVF-if not resolved: -norepinephrine-if not resolved: -norepinephrine -dopamine-dopamine -combined norepinephrine and dobutamine-combined norepinephrine and dobutamine

ANTICOAGULANT THERAPY:ANTICOAGULANT THERAPY:Anticoagulant therapy reduces mortality and is considered primary Anticoagulant therapy reduces mortality and is considered primary

therapy for PE. The goal of anticoagulation is to decrease mortality therapy for PE. The goal of anticoagulation is to decrease mortality by preventing recurrent PE.by preventing recurrent PE.

For patients in whom there is a high clinical suspicion of PE and no For patients in whom there is a high clinical suspicion of PE and no excess risk of bleeding, empiric anticoagulation should be initiated excess risk of bleeding, empiric anticoagulation should be initiated immediately and continued during the diagnostic evaluation.immediately and continued during the diagnostic evaluation.

Heparin:Heparin: Dose :loading: 80U/Kg IVDose :loading: 80U/Kg IV :maintenance :18U/Kg/h:maintenance :18U/Kg/h T ½ : 90mT ½ : 90m Route of administration: IV/SCRoute of administration: IV/SC Duration :7-10 d Duration :7-10 d Reversal :stop heparin Reversal :stop heparin protamine sulphate :1U neutralize 100 IU heparin protamine sulphate :1U neutralize 100 IU heparin No FFPNo FFP

• LMWH:LMWH:-Dose :brand dependent -Dose :brand dependent -Mechanism of action :anti-X > anti-II-Mechanism of action :anti-X > anti-II-Route of administration :IV or S/C-Route of administration :IV or S/C-Monitoring : not indicated -Monitoring : not indicated -Indication for monitoring : pregnancy ,morbid obesity , sever renal or -Indication for monitoring : pregnancy ,morbid obesity , sever renal or

liver derangement liver derangement -Duration : 7-10 d-Duration : 7-10 d-Reversal :stop heparin -Reversal :stop heparin protamine sulphate :un-predictable responseprotamine sulphate :un-predictable response

Warfarin:Warfarin:-Route of administration: P.O-Route of administration: P.O-Monitoring :INR-Monitoring :INR-Desired target INR:2.5-Desired target INR:2.5

Further management:Further management:

-Thrombolysis.-Thrombolysis.

-IVC filter.-IVC filter.

-Embolectomy-Embolectomy