Group 16: H.Cotton, G. Edwards, C. Harrison, A. Wilcock, A.Williams

1. Group 16: H.Cotton, G. Edwards, C. Harrison, A. Wilcock, A.Williams Not so swell…

2. Presenting complaint 69 Retired sawmill worker presented to A&E via ambulance with Haemoptysis

3. Recap ....Haemoptysis (The expectoration of blood or bloodstained sputum) 1. 2. 3. Trachea or bronchus • Malignancy • Chronic Bronchitis • Bronchiectasis • Airway trauma Lung parenchyma • Pneumonia - bacterial (e.g.Staphylococcus aureus, Pseudomonas aeruginosa) or viral (e.g. influenza)* • Tuberculosis (TB) • Goodpasture's syndrome • Wegners Granulomatosis • Pulmonary haemorrhagic syndrome Vascular • Pulmonary embolism (PE) • Pulmonary Hypertension-Mitral stenosis

4. History of presenting complaint 5 weeks SOB on short distances 2 weeks Viral cold Cough producing yellow sputum 2 weeks Loss of appetite No weight loss 8 days Bilateral oedema of legs from feet to scrotum. Gradual onset 3 hours Left sided chest pain 3 hours Haemoptysis

5. PMH/Drugs History 1990 Trauma to left lower leg- plate and pins inserted after motor bike accident. Denies calf pain and no recent trauma No recent travel/ long flights/ recent surgery/ immobilisation No other Hx Drugs History Nil medication No known allergies

6. Social and Family Hx Social Hx Lives with daughter Wife died Sept 2010- breast Ca Previous smoker 8-10 cigarettes per day for 20 years. Quit 15-20 years ago Alcohol – nil never heavy Family Hx Father died-CVA (aged 70) Mother died-CVA (aged 85) Sister died-CVA (aged 60) Second sister died (aged 50)-congenital heart condition Brother-diabetes mellitus

7. On examination General appearance; Relaxed, well perfused, slightly breathless, no obvious pain. • Pulse regular • Tachycardia (121) • No identifiable JVP • Heart sounds I+II+0 • Bilateral pitting leg oedema • to the scrotum OBS Temp 37.1 Pulse 121 RR 14 O2 97% BP 127/103 GCS 15 BMI 24 Bilateral basal crepitations Left > right No abnormalities No dizziness No headaches Some lower limb weakness

8. Differentials?

9. Differential diagnoses Myocardial Infarction Unstable Angina Pulmonary Embolism TB COPD Pneumonia Lung carcinoma

10. Investigations • Bloods • FBC • U&E • CRP • D-dimer • LFT • ABG • ECG • CXR

11. Bloods

12. ABG Results Taken 20/03/11 at 08:35am

13. ECG T wave inversion T wave inversion Dominant R wave in V1 Left axis deviation Broad QRS complex >0.12s Deep S waves in lateral leads

14. CXR • Raised right hemidiaphragm • Pulmonary oedema • Left costophrenic angle can’t be seen

15. CT Large PE seen in the left superior pulmonary artery and further PE seen in separated L and R pulmonary arteries. Moderate sized bilateral pleural effusion. Bilateral lower lobe consolidation Mild COPD changes seen Cardiomegaly Normal appearance of liver and spleen visualised

16. Impression • PE with right sided heart failure • Pneumonia • Plan • Find cause of PE • CTPA • Rx LMWH • Sputum culture • Echo right ventricle • Antibiotics • Prostate Specific Antigen • Cardiac review

17. ABCDE approach A –airway. Is patient talking? Open airway and inspect. Give O2. B– breathing. Inspect, palpate, percuss, auscultate. Ventilate if RR <10. C– circulation. Pulses, cap refill and BP. IV access. D – disability. AVPU or GCS. Pupils. BM’s. E – exposure. Head-to-toe exam. REASSESS! A B C D E

18. Pathway in A&E - suspected PE Patients with pleuritic chest pain/possible PE 1 Assess Clinical risk2 LOW D Dimer Normal Raised Moderate/High Low Molecular Weight Heparin Consider another diagnosis No PE CT Pulmonary Angiography Yes Abnormal CXR No VQ Scan Normal abnormal PE

19. Well’sCriteria Our patient’s score= 2.5 <2 Low probability 2-6 Moderate probability >6 High probability

20. VQ scan and CTPA • VQ Scan • Expensive • Not always available • Reduced specificity if chest-x-ray abnormalities present CTPA • Gold standard for diagnosis of PE • Assess volume of clot • Sensitivity> 95% • Can detect alternative • diagnosis if no PE seen • Higher radiation dose • Cheaper than VQ Scan

21. 100% O2 ABCDE approach Morphine 10mg IV Give LMWH Dalteparin 5,000 units SC loading dose, to increase based on weight If critically ill and large PE, give immediate thromoblysis with 50mg bolus Alteplase or consider surgery Systolic BP Acute management of PE Sys BP <90mmHg, give 500ml rapid colloid infusion Sys BP >90mmHg, give Warfarin 10mg/24h PO Give Dobutamine and Noradrenaline if BP still <90mmHg

22. Medication • Commenced in A&E • Co-amoxiclav 1.2g IV • Dalteparin 5,000units • In MAU • Dalteparin 15,000units • Furosemide 40g BD PO • In AM1 • Dalteparin 15,000units • Furosemide 40g BD PO • Co-amoxiclav 625mg TDS PO

23. Final Investigations • 25/03/11 - Doppler ultrasound scan of bilateral lower limb deep veins performed • Right leg – Occlusive thrombus in one peroneal vein. Non-occlusive thrombus in one posterior tibial vein • Left leg – Occlusive and non-occlusive thrombus present in superficial femoral vein. Old non-occlusive thrombus throughout posterial tibial vein • Conclusion – Right calf DVT, and left chronic femoral and calf DVT • 25/03/11 - Echocardiogram showed mild to moderate mitral regurgitation. Dilation of the left atrium and left ventricle with globally poor function. • Ejection fraction < 20%

24. Pulmonary Embolism Blockage of the main artery of the lung or one of its branches by an embolus. • Higher in Afro-Caribbean • 1 in 1000 cases per year • Untreated PE mortality is 26% Sudden Catastrophic Haemodynamic Collapse Gradually Progressive Dyspnoea Typical Clinical Presentation : 1. Massive Pulmonary Embolism 5 : 4 2. Acute Embolism with Infarction 3. Acute Embolism without Infarction 4. Multiple Pulmonary Emboli

25. Pathophysiology of PE Pulmonary Embolism is a complication of an underlying problem

26. Virchow’s triad • Immobility/paralysis • LV dysfunction • Venous obstruction from tumour, obesity or pregnancy Circulatory Stasis • Trauma/ surgery • Atherosclerosis • Hypertension • Indwelling catheters • Malignancy • Pregnancy & peri-partum • Oestrogen therapy • Thrombophilia Thrombosis Endothelial Injury Hypercoagulable State

27. Causes / Risk Factors reduced mobility old age malignancy acute medical illness trauma & major surgery medication pregnancy smoking obesity • Hereditary Factors Acquired Factors genetic thrombophilia

28. Further Thoughts • Multiple thrombi found in lower limbs (thought to be the source of the pulmonary embolus) • Medics now querying possible malignancy as a reason for thrombi development.

29. Malignancy and PE • Active cancer is linked to an increased risk of PE events. • Adenocarcinomas and haematological malignancies are specifically noted to increase the risk. • Malignant cells can directly activate blood coagulation by producing tissue factor, cancer procoagulant activity, inflammatory reactions and cytokines. • Inflammation induced by cancer can in turn increase acute-phase proteins, which can promote thrombosis

30. Summary • Pt presented with haemoptysis, chest pain and bilateral oedema • This was found to be an extensive PE, caused by multiple DVTs in both legs • This has led to R sided HF, with ejection fraction <20% • Further causes are still being investigated, and malignancy is being queried

31. Any Questions ???? Thank-you