Pulmonary Embolism

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Pulmonary Embolism DVT
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Introduction

• Pathophysiology
• Risk Factors
• Symptoms
• Lab Findings
• Radiology Findings
• Treatment
• Prevention

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Pathophysiology

• Dislodgement of a blood clot
• Lower Extremities 65 to 90
• Pelvic venous system
• Renal venous system
• Upper Extremity
• Right Heart

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Risk Factors for PE and DVT

• Immobilization
• Surgery within the last 3 months
• Stroke
• History of venous thromboembolism
• Malignancy
• Preexisting respiratory disease
• Chronic Heart Disease
• Age gt60
• Surgery requiring gt30mins of anesthesia

• Recent travel (past 2weeks, gt4 hours)
• Varicose veins
• Superficial vein thrombosis
• Central VV catheter/port/pacemaker
• Additional RF in Women
• Obesity BMI gt/29
• Heavy smoking (gt25cigs/day)
• Hypertension
• Pregnancy

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Wells Criteria
Clinical Signs and Symptoms of DVT? (Calf tenderness, swelling gt3cm, errythema, pitting edema affected leg only) 3
PE Is 1 Diagnosis, or Equally Likely 3
Heart Rate gt 100 1.5
Immobilization at least 3 days, or Surgery in the Previous 4 weeks 1.5
Previous, objectively diagnosed PE or DVT? 1.5
Hemoptysis 1
Malignancy w/ Rx within 6 mo, or palliative? 1
gt6 High Risk 2 to 6 Moderate Risk 2 or
less Low Adapted with permission from Wells PS,
Anderson DR, Rodger M, Ginsberg JS, Kearon C,
Gent M, et al. Derivation of a simple clinical
model to categorize patients probability of
pulmonary embolism increasing the models utility
with the SimpliRED d-dimer. Thromb Haemost
200083416-20.
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P.E. and Malignancy

• A Presenting sign in
• Pancreatic cancer
• Prostate cancer
• Late sign in
• Breast cancer
• Lung cancer
• Uterine cancer
• Brain cancer

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Symptoms of P.E.

• Dyspnea
• Pleuritic pain
• Cough
• Hemoptysis (blood tinged/streaked/ pure blood)

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Signs of P.E.

• Tachypnea
• Rales
• Tachycardia
• Hypoxia
• S4
• Accentuated pulmonic component of S2
• Fever T lt102 F

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Signs in Massive P.E.

• Massive PE hemodynamic instability with SBP
  lt90 or a drop in baseline SBP by gt/40mmHg
• Signs as before PLUS
• Acute right heart failure
• Elevated J.V.P.
• Right-sided S3
• Parasternal lift

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P.E. Leg Symptoms

• Most patients with P.E. do not have leg symptoms
  at time of diagnosis
• Patients with leg symptoms may have asymptomatic
  P.E.

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Lab Radiologic Findings in P.E.

• ABG
• BNP
• Cardiac Enzymes Troponin
• D-dimer
• EKG
• CXR
• Ultrasound
• V/Q Scan
• Angiography

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Lab Findings in P.E.(ABG)

• ABG
• Hypoxemia
• Hypocapnia (low CO2)
• Respiratory Alkalosis
• Massive PE hypercapnia, mix resp and metabolic
  acidosis (inc lactic acid)
• Patients with RA pulse ox readings lt95 are at
  increased risk of in-hospital complications, resp
  failure, cardiogenic shock, death

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Lab Findings in P.E. (BNP)

• BNP (beta natruretic peptide)
• Insensitive test
• Patients with PE have higher levels than pts
  without, but not ALL patients with PE have high
  BNP
• Good prognostic value measure if BNP gt90
  associated with adverse clinical outcomes (death,
  CPR, mechanical vent, pressure support,
  thrombolysis, embolectomy)

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Lab Findings in P.E. (Troponin)

• Troponin
• High in 30-50 of pts with mod to large PE
• Prognostic value if combined pro-NT BNP
• Trop I gt0.07 NT-proBNP gt600 high 40 day
  mortality

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Lab Findings in P.E. (D-dimer)

• D-dimer
• Degredation product of fibrin
• gt500 is abnormal
• Sensitivity High, 95 of PE pts will be positive
• Specificity Low
• Negative Predictive Value Excellent

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S1Q3T3!!!
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RAD Right Atrial Enlargement
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Lab Findings in P.E. (contd)

• EKG
• 2 Most Common finding on EKG
• Nonspecific ST-segment and T-wave changes
• Sinus Tachycardia
• Historical abnormality suggestive of PE
• S1Q3T3
• Right ventricular strain
• New incomplete RBBB

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Radiologic Findings in P.E.
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GOLD STANDARD IN DIAGNOSING PULMONARY EMBOLISM?

• PULMONARY ANGIOGRAM

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Radiology Findings in P.E. (contd)

• CXR
• Normal
• Atelectasis and/or pulmonary parenchymal
  abnormality
• Pleural Effusion
• Cardiomegally

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Whats This???
Hamptons Hump
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How About This???
Westermark's Sign an abrupt tapering of a vessel
caused by pulmonary thromboembolic obstruction.
This CXR shows enlargement of the left hilum
accompanied by left lung hyperlucency, indicating
oligemia (Westermark's sign).
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Radiology Findings in P.E. (contd)

• V/Q Scan
• Results High, Intermediate, Low Probability
• Best if combined with Clinical Probability
  (PIOPED study)
• High Clinical Prob High Prob VQ 95 likelihood
  of having a P.E.
• Low Clinical Prob Low Prob VQ 4 likelihood of
  having a P.E.

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Radiology Findings in P.E. (contd)

• Lower Extremity Ultrasounds
• If DVT found then treatment is same if patient
  has a P.E.
• Disadvantage
• If negative, patients with PE may be missed
• If false positive (3), unnecessary intervention

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Radiology Findings in P.E. (contd)

• CT Pulmonary Angiography (CT-PA)
• Widely used
• Institution dependent
• Sensitivity (83)
• Specificity (96) if negative, very low
  likelihood that pt has P.E.

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Radiology Findings in P.E. (contd)

• Pulmonary Angiogram
• Gold Standard
• Not easily accessible
• Radiologist dependent

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Radiology Findings in P.E. (contd)

• Echocardiogram
• Increased Right Ventricle Size
• Decreased Right Ventricular Function
• Tricuspid Regurgitation
• Rarely
• RV thrombus
• Regional wall motion abnormalities that spare the
  right ventricle apex (McConnells Sign)

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Hypercoagulability Work Up

• No consensus on who to test
• Increased likelihood if
• Age lt50y/o without immediate identifiable risk
  factors (idiopathic or provoked)
• Family history
• Recurrent clots
• If clot is in an unusual site (portal, hepatic,
  mesenteric, cerebral)
• Unprovoked upper extremity clot (no catheter, no
  surgeries)
• Patients with warfarin induced skin necrosis
  (they may have protein C deficiency

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Hypercoagulability Work Up

• Protein C/S deficiency
• Factor V leiden deficiency
• AntiThrombin III deficiency
• Prothrombin 20210 mutation
• Antiphospholipid antibody
• High Homocysteine

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Most Common Cause of Congenital Hypercoagulablity

• Protein C resistance d/t Factor V leiden mutation

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Treatment of P.E.

• Respiratory Support Oxygen, intubation
• Hemodynamic Support IVF, vasopressors
• Anticoagulation
• Thrombolysis
• IVC Filter

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Anticoagulation

• Start during resuscitation phase itself
• If suspicion high, start emperic anticoagulation
• Evaluate patient for absolute contraindication
  (i.e. active bleeding)

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Anticoagulation (contd)

• HEPARIN
• Lovenox if hemodynamically stable, no renal
  function
• 1mg/kg BID OR 1.5mg/kg QDay
• Heparin gtt if hypotension, renal failure
• 80units/kg bolus then 18units/kg infusion
• Goal PTT1.5 to 2.5 times the upper limit of
  normal
• COUMADIN
• Start once acute anticoagulation achieved
• Start with 5mg PO qday OR 10mg PO q day
• If start with 10mg then achieve therapeutic INR
  1.4 days sooner
• Complications and morbidity no different in 5mg
  or 10mg start
• Goal INR 2 to 3

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Duration of Anticoagulation for DVT or PE
Event Duration Strength of Recommendation
First Time event of Reversible cause (surgery/trauma) At least 3 mos A
First episode of idiopathic VTE At least 6 mos A
Recurrent idiopathic VTE or continuing risk factor (e.g., thrombophilia, cancer) At least 12 mos B
Symptomatic isolated calf-vein thrombosis 6 to 12 weeks A
From American College of Chest Physicians
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Thrombolysis

• Considered once P.E. diagnosed
• If chosen, hold anticoagulation during
  thrombolysis infusion, then resumed
• Associated with higher incidence of major
  hemorrhage
• Indications persistent hypotension, severe
  hypoxemia, large perfusion defecs, right
  ventricular dysfunction, free floating right
  ventricular thrombus, paten foramen ovale
• Activase or streptokinase

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IVC Filter

• Indication
• Absolute contraindication to anticoagulation
  (i.e. active bleeding)
• Recurrent PE during adequate anticoagulation
• Complication of anticoagulation (severe bleeding)
• Also
• Pts with poor cardiopulmonary reserve
• Recurrent P.E. will be fatal
• Patients who have had embolectomy
• Prophylaxis against P.E. in select patients
  (malignancy)

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Embolectomy

• Surgical or catheter
• Indication
• Those who present severe enough to warrant
  thrombolysis
• In those where thrombolysis is contraindicated or
  fails

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Questions?