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Pulmonary Embolism

Pulmonary Embolism. Prof. Ahmed BaHammam, FRCP, FCCP Professor of Medicine College of Medicine King Saud University. Phlegmasia cerulea dolens Venous gangrene. Color duplex scan of DVT. Venogram shows DVT. Patient with suspect symptomatic Acute lower extremity DVT. negative.

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Pulmonary Embolism

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  1. Pulmonary Embolism Prof. Ahmed BaHammam, FRCP, FCCP Professor of Medicine College of Medicine King Saud University

  2. Phlegmasia cerulea dolens Venous gangrene

  3. Color duplex scan of DVT

  4. Venogram shows DVT

  5. Patient with suspect symptomatic Acute lower extremity DVT negative Venous duplex scan Low clinical probability observe High clinical probability positive negative Evaluate coagulogram /thrombophilia/ malignancy Repeat scan / Venography IVC filter Anticoagulant therapy contraindication yes No pregnancy LMWH OPD LMWH + warfarin hospitalisation UFH Compression treatment

  6. Thrombophilia screeningFactor V leiden, Prot C/S deficiency Antithrombin III deficiency • Idiopathic DVT < 50 years • Family history of DVT • Thrombosis in an unusual site • Recurrent DVT

  7. Recommendation for duration of warfarin • 3-6 months first DVT with reversible risk factors • At least 6 months for first idiopathic DVT • 12 months to lifelong for recurrent DVT or first DVT with irreversible risk factors malignancy or thrombophilic state

  8. Catheter directed-thrombolysis • Consider in: Acute< 10 days iliofemoral DVT. • Long-term benefit in preventing post-phebitic syndrome is unknown.

  9. 50,000 individuals die from PE each year in USA • The incidence of PE in USA is 500,000 per year

  10. Incidence of Pulmonary Embolism Per Year in the United States* Total Incidence 630,000 89% 11% Survival >1hr 563,000 Death within 1 hr 67,000 71% 29% Dx not made 400,000 Dx made, therapy instituted 163,000 *Progress in Cardiovascular Diseases, Vol. XVII, No. 4 (Jan/Feb 1975) 70% 30% 92% 8% Survival 280,000 Death 120,000 Survival 150,000 Death 120,000

  11. Risk factor for venous thrombosis • Stasis • Injury to venous intima • Alterations in the coagulation-fibrinolytic system

  12. Source of emboli • Deep venous thrombosis (>95%) • Other veins: • Renal • Uterine • Right cardiac chambers

  13. Risk factors for DVT • General anesthesia • Lower limb or pelvic injury or surgery • Congestive heart failure • Prolonged immobility • Pregnancy • Postpartum • Oral contraceptive pills • Malignancy • Obesity • Advanced age • Coagulation problems

  14. Clinical features • Sudden onset dyspnea • Pleuritic chest pain • Hemoptysis • Clinical clues cannot make the diagnosis of PE; their main value lies in suggesting the diagnosis

  15. Massive Pulmonary Embolism • It is a catastrophic entity which often results in acute right ventricular failure and death • Frequently undiscovered until autopsy • Fatal PE typically leads to death within one to two hours of the event

  16. Pathophysiology • Massive PE causes an increase in PVR  right ventricular outflow obstruction decrease left ventricular preload  Decrease CO • In patients without cardiopulmonary disease, occlusion of 25-30 % of the vascular bed  increase in Pulmonary artery pressure (PAP) • Hypoxemia ensues  stimulating vasoconstriction  increase in PAP

  17. Pathophysiology • More than 50% of the vascular bed has to be occluded before PAP becomes substantially elevated • When obstruction approaches 75%, the RV must generate systolic pressure in excess of 50mmHg to preserve pulmonary circulation • The normal RV is unable to accomplish this acutely and eventually fails

  18. Diagnosis • CXR • ABG: • ECG • V/Q • Spiral CT • Echo • Angio • Fibrin Split Products/D-dimer

  19. S1 Q3 T3 Pattern

  20. T-wave inversion

  21. Rt. Bundle Branch Block

  22. Rt. Ventricular Strain

  23. Diagnosis The diagnosis of massive PE should be explored whenever oxygenation or hemodynamic parameters are severely compromised without explanation • CXR • ABG: • Significant hypoxemia is almost uniformly present when there is a hemodynamically significant PE • V/Q • Spiral CT • Echo • Angio

  24. Chest radiograph showing pulmonary infarct in right lower lobe

  25. High-probability ventilation-perfusion scan

  26. High-probability ventilation-perfusion scan

  27. High-probability ventilation-perfusion scan

  28. Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) results

  29. Spiral CT

  30. Spiral CT

  31. Spiral CT

  32. Before After

  33. Tomographic scan showing infarcted left lung, large clot in right main pulmonary artery

  34. Before After

  35. Pulmonary angiogram

  36. Pulmonary Angiogram

  37. MRA with contrast

  38. MRA Real Time

  39. PULMONARY EMBOLISM

  40. Sensitivity of spiral computed tomography, magnetic resonance angiography, and real-time magnetic resonance angiography, for detecting pulmonary emboli Reader 1 2 Mean K CT 72.1 69.8 71.0 0.86 MRA 79.1 81.4 80.3 0.84 RT-MRA 97.7 97.7 97.7 1 Am J Respir Crit Care Med 2003

  41. Suggested diagnostic strategy for venous thromboembolism

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