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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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This is the real thing
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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Overview of Basic Science
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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Overview of Basic Science
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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Diagnosis Minimizing Risk &
Maximizing Resources
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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Diagnosis Minimizing Risk &
Maximizing Resources
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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Diagnosis Minimizing Risk &
Maximizing Resources
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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Diagnosis Minimizing Risk &
Maximizing Resources
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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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Putting it all Together in Practice
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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Putting it all Together in Practice
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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Putting it all Together in Practice
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