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Pulmonary Embolism Diagnosis, Treatment, and Prevention

Pulmonary Embolism Diagnosis, Treatment, and Prevention. Philip Keith March 26, 2008. Pulmonary Embolism. Thrombosis that originates in the venous system and embolizes to the pulmonary arterial circulation DVT in veins of leg above the knee (>90%)

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Pulmonary Embolism Diagnosis, Treatment, and Prevention

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  1. Pulmonary EmbolismDiagnosis, Treatment, and Prevention Philip Keith March 26, 2008

  2. Pulmonary Embolism • Thrombosis that originates in the venous system and embolizes to the pulmonary arterial circulation • DVT in veins of leg above the knee (>90%) • DVT elsewhere (pelvic, arm, calf veins, etc.) • Cardiac thrombi

  3. How Common? • 650,000 cases in the US each year • 150,000 – 200,000 US deaths each year • Most common preventable cause of hospital death • 3rd most common acute cardiovascular emergency (MI and stroke)

  4. Risk Factors (for DVT) • Virchow’s Triad • Alterations in blood flow (stasis): best rest, inactivity/immobilization, CHF, paralysis • Injury to endothelium: trauma, surgery • Thrombophilia: Factor V Leiden, Protein C or S deficiency, etc. • Age >50 • History of varicose veins • History of MI • History of malignancy • History of atrial fibrillation • History of ischemic stroke • History of diabetes mellitus • Previous VTE, obesity, pregnancy

  5. Clinical Presentation • Asymptomatic • Sudden onset of unexplained dyspnea • Pleuritic chest pain • Tachypnea • Tachycardia • Anxiety/agitation, cough, hemoptysis, syncope, fever, cyanosis, isolated crackles, pleural friction rub, loud P2, right-sided S3, pulmonary insufficiency murmur, elevated JVP, right ventricular heave, acute worsening of heart failure or lung disease

  6. Broad Differential • Pneumothorax • Myocardial ischemia • Pericarditis • Asthma • Pneumonia • MI with cardiogenic shock • Cardiac tamponade • Aortic dissection • etc, etc, etc

  7. Nonspecific Workup • Chest X-ray: abnormal in 88% of acute PE • Atelectasis (60-70%): most common finding in PE without infarction • “Classic” findings: • Westermark sign (increased lucency in area of embolus) • Hampton Hump (wedge-shaped pleural-based infiltrate) • Abrupt cutoff of vessel • Pleural effusion • EKG • Most common: sinus tachycardia +/- nonspecific ST-segment and T-wave changes • “Classic S1-Q3-T3 pattern” • Other signs of right heart strain (ie, new RBBB and ST changes in V1,2 • ABG • Normal does NOT rule out PE • “Classic” findings: • Hypoxia, hypocapnia, respiratory alkalosis, increased A-a gradient

  8. Westermark Sign

  9. Hampton Hump Occurs 12 to 36 hours after symptoms begin; usually indicates pulmonary infarction

  10. EKG Findings

  11. Evaluation and Diagnosis • Evaluation and imaging is dependent upon estimated pretest probability (Modified Wells’ Criteria) • Pretest probability: • Low (<2 points) • Intermediate (2-6 points) • High (>6 points)

  12. REFER TO ALGORITHM

  13. D-dimer in evaluation of PE • High sensitivity but poor specificity • Negative ELISA has >95% negative predictive value and can be used to r/o PE in low risk patients (less than 2 points)

  14. Helical CT • Sensitivity 85% (more sensitive for proximal emboli) • Specificity 95% • Values vary widely in literature

  15. Bilateral PE

  16. V/Q Scan • Identifies mismatches between areas that are ventilated but not perfused • Best initial test in patients with clear CXR • Scan can be interpreted as High, Intermediate, or Low probability of PE, or normal • Normal rules out PE • High-probability scan is diagnostic of PE if the clinical suspicion is also high • Low-probability scan rules out PE only in a pt with low pretest clinical probability (because PE is found in roughly 15% of pts with low-probability scans) • Intermediate-probability scan requires further evaluation (16-66% chance of PE depending on pretest probability)

  17. V/Q Scan

  18. Duplex US with compression of the lower extremities • Non-invasive test that accurately detects proximal DVT in LE (70-80% of pts with PE have concomitant proximal DVT) • Often used in workup of PE before going to more invasive procedures • SEE ALGORITHM

  19. Pulmonary Angiography • “Gold Standard” • Invasive study • 5% morbidity • < 0.5% mortality • Indicated if the diagnosis remains uncertain after noninvasive testing

  20. PE on pulmonary angiogram

  21. Treatment of PE • Acute anticoagulation to therapeutic levels • IV UFH: 80 U/kg bolus, then 18 U/kg/hr to goal PTT of 46-70 seconds OR • LMWH: ie) lovenox 1 mg/kg SUBQ BID then start warfarin (when PTT is therapeutic on UFH or on day 1 of LMWH), overlap x 5 days, titrate to INR 2.0 to 3.0 • Thrombolysis: for massive PE causing hemodynamic compromise • IVC Filter: if anticoagulation is contraindicated (ie, active GI bleed, intracranial neoplasm, know bleeding diathesis), if thrombus formed despite adequate anticoagulation, or with a large burden of thrombosis in the LE that could be fatal if embolized

  22. Treatment of PE • Long-term anticoagulation • 1st event with reversible RF: 3-6 mo warfarin • Idiopathic PE/DVT: > or = 6 mo warfarin • 2nd event, cancer, non-modifiable RF: 12 mo to lifelong warfarin • LMWH has been shown to be superior to warfarin in long term treatment in pts with cancer

  23. DVT/PE Prophylaxis • Moderate to High Risk Patients (>2 RF) • Lovenox 30 mg SUBQ q 12 hours OR • Lovenox 40 mg SUBQ daily • SCD at all times except when ambulating • Low to Moderate Risk Patients ( 1 RF) • Lovenox 40 mg SUBQ daily OR • SCD at all times except when ambulating • No Risk Factors • Ambulate in hallways or room QID • TED hose or SCD

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