Pulmonary embolosm

PE
•Pulmonary embolus (PE) refers to obstruction
of the pulmonary artery or one of its branches
by materials like thrombus, tumor, air, or fat,
that originated elsewhere in the body.
•Thrombi originate from venous thrombi (DVT)
in leg or paradoxically through a Patent
Foramen Ovale or Atrial Septal Defect.
3 tytpes of presentation
• Acute – Patients with acute PE develop
symptoms and signs immediately after
obstruction of pulmonary vessels.
• Subacute – Some patients with PE may also
present subacutely within days or weeks
following the initial event.
• Chronic – Patients with chronic PE slowly
develop symptoms of pulmonary hypertension
over many years
Risk factors
Acquired causes Inherited causes

Prolonged travel, Immobility,DVT Factor V Leiden mutation

Obesity, Antithrombin III deficiency
Smoking Protein C, S deficiency
Surgery, Trauma
Hormone replacement
therapy(oestrogen)
Oral contraceptives
Antiphospholipid antibody syndrome
Malignancy,
Old age
Clinical features
Symptoms Signs
History of DVT Tachypnoea, Hypoxia,
Sudden chest pain, Cyanosis, tachycardia
cough with Hemoptysis, Hypotension(Due to RV failure)
breathlessness, Elevated JVP
pleuritic pain Loud P2,
Syncope Acute Cor-Pulmonale
Low grade fever
Mortality rate of acute PE is approximately 30% without treatment
Wells criteria and modified Wells criteria: clinical
assessment for PE
Clinical 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
Probability Score
Traditional clinical probability assessment (Wells criteria)
High >6.0
Moderate 2.0 to 6.0
Low <2.0
Simplified clinical probability assessment (Modified Wells criteria)
PE likely >4.0
PE unlikely ≤4.0
Investigation
• Plasma D-dimer (ELISA) – Elevated > 500 ng/ml (It is a fibrin
breakdown product),It is very sensitive(>95%) for PE
• But not specific:It can be elevated in MI, Pneumonia, Sepsis
• A low D dimmer rules out PE
• A false negative D-dimer is a feature seen in patients on anticoagulant
therapy(Eg patients receiving anticoagulant for previous DVT or PE)
• ABG – Both PO2 and PCO2 are reduced
• ECG – Sinus Tachycardia(most common finding),Inverted T
wave in V1-V4, new onset Atrial Fibrillation, RBBB,RVH,
S1Q3T3(classical finding but not common)
• Most common is tachycardia
• S1Q3T3 – S wave in lead I, Q wave in lead III, inverted T wave in lead
III
S1Q3T3
X ray chest
• Oligaemia of lung fields(Westermark’s sign)
• Elevated diaphragm
• Wedge shaped pulmonary opacities above the
diaphragm(Hampton’s hump)
• Pleural Effusion
• Enlarged pulmonary artery

Westermark sign Hamptons hump

Echo
• Increased RV size
• Decreased RV function
• Tricuspid regurgitation
• Abnormal septal wall motion: RV free wall hypokinesis,
and interventricular septal flattening
• McConnell's sign: Regional wall motion abnormalities
that spare the right ventricular apex
• Right heart thrombus
Imaging
• Ventilation perfusion scanning (V/Q scanning)
• Ventilation perfusion mismatch (Ventilation normal with
reduced perfusion)
• Normal V/Q scan rules out PE
• CT chest with contrast, MDCT
• Colour Doppler of leg veins to rule out DVT
• CT Pulmonary Angiography(CTPA)
• It is most specific, it can detect emboli as small as 1 to 2 mm
Procoagulant workup
• Antiphospholipid antibodies – Anti cardiolipin antibody-IgG
and IgM, Lupus anticoagulant, Beta 2 glycoprotein 1
antibodies- IgG and IgM
• Fasting plasma homocysteine levels
• Flow cytometry in PNH
• Protein C and S levels
• Antithrombin III levels
• Factor V Leiden PCR
• Prothrombin 20210 mutation testing by PCR
Initail Management
• Supportive Therapy
• ABC
• Oxygen, Morphine with caution
• Fluids, norepinephrine,
• Dobutamine in cardiogenic shock
Antithrombotic therapy
• Heparin 5000 U bolus(80U/kg), then continuous infusion of 1000
units/hour(18U /kg/hr), monitor aPTT (Keep 2 times above
control), 5 days
• Low Molecular Weight Heparin – Enoxaparin 1.5 mg/Kg daily 5 days
• Fondaparinux (Factor Xa inhibitor) - 5 mg SC OD( <50 Kg ), 7.5 mg SC
OD( 50-100 Kg )
• Warfarin
• Start along with heparin
• In average sized patient – 5 mg/day
• In obese – 7.5 to 10 mg/day
• In malnourished – 2.5 mg/day
• Keep INR around 2.5 (2 to 3)
Thrombolytic Therapy
• In massive Pulmonary Embolism
• Recombinant tissue plasminogen activator (rt-PA; alteplase – 10 mg IV
bolus then 90 mg infused over 2 hours)
• Streptokinase, urokinase