Pulm Embolus

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Morning Report 8/16/2000
Victor Ghobrial, MD
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HPI

• 63 WM admitted to Myersdale Hosp with Hemoptysis
  and CP
• Rt sided CP started three days prior to
  admission, a day after was followed by
  hemoptysis.
• No SOB, fever, sputum or other symptoms.

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PMH

• CAD S/P RCA stent 3 yrs before.
• Chronic depression.
• Gout.
• Hemorrhidectomy
• Lt inguinal hernial repair
• Rt inguinal hernial repair
• No HTN, DM, DVT, TB or CA

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Personal Hx

• Smoked 3 packs of cigarettes daily for 20 yrs,
  quitted 20 yrs ago.
• Works as a dye maker.
• Family Hx ve CAD, DM and HTN

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Physical Exam

• 63 male in no acute respiratory distress
• Temp Pulse B/P R/R
  99
  72 120/60 24
• HEENT unremarkable
• Neck supple with no JVD or lymphadenopathy
• Heart RRR, S1S2 audible without murmurs

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Physical Exam

• Lungs Bibasilar rales with dullness to
  percussion and decreased breath sounds at bases
  more on the Rt than the Lt
• Abdomen soft, non tender, no organomegally
• Extre no edema or cyanosis with PP
• Neuro AAOx3 without focal deficits

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Where do you wanna go ?
Hemoptysis
Chest pain
Depression
Ex smoker
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Hemoptysis

• Expectoration of blood from below Vocal cords,
  can range from blood-streaking of sputum to
  massive hemoptysis 100 to gt600 ml/ 24 h.
• Commonest causes are
  Infection (
  bronchitis, pnumonia)
  Tumors
  Bronchiactasis

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EVALUATION OF HEMOPTYSIS

• History and physical
• Chest radiograph.
• Laboratory studies (H/H, renal function and
  coagulation profile) .
• Fiberoptic bronchoscopy
• High-resolution CT scanning (HRCT)

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Our patients Labs

• Hgb WBCs Plateles
  12.7 13.4
  132,000
• PT PTT
  12.9 35
  
• Na K Cl BUN Cr
  CO2 135 3.7 101
  14 1.1 29

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Studies

• CXR (show)
• CT Chest (show)

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Pulmonary Embolism

• Annual incidence 300,000 cases, resulting in
  approximately 50,000 deaths per year.
• Two-thirds remain undiagnosed.
• Without treatment, mortality rate 30 , primarily
  the result of recurrent embolism.

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Pulmonary emboli

• Originate in the deep venous system of the lower
  extremities
• Iliofemoral thrombi appear to be the source of
  most clinically recognized PE
• Calf vein thrombi About 20 percent propagate to
  the popliteal, femoral, or iliac veins

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Risk Factors

• Immobilization
• Surgery within the last three months
• Stroke
• History of venous thromboembolism
• Malignancy

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without identifiable risk factors

• Factor V Leiden in 40 of cases.
• High concentrations of factor VIII a 6-fold risk
  for venous thromboembolism
• Occult malignancy present in 17 (presenting sign
  of pancreatic or prostate cancers, whereas late
  in the course of patients with breast, lung,
  uterine, or brain malignancies)

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The most common symptoms

• Dyspnea (73 percent)
• Pleuritic pain (66 percent)
• Cough (37 percent)
• Hemoptysis (13 percent).

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The most common signs

• Tachypnea (70 percent)
• Rales (51 percent)
• Tachycardia (30 percent)
• A fourth heart sound (24 percent)
• An accentuated pulmonic component of the second
  heart sound (23 percent).

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Radiography

• The most frequent radiographic abnormalities
  noted in PIOPED were atelectasis or a pulmonary
  parenchymal abnormality.
• Pleural effusion was noted in 47 and 39 percent
  of patients with and without pulmonary embolism,
  respectively.

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Electrocardiogram

• Tachycardia
• Non-specific EKG changes
• Rt sided Ht strain

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D-Dimer

• High negative predictive value
• If negative excludes PE except in 10 of cases
• If positive does not necessarily diagnose PE

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Noninvasive tests for lower extremity venous
thrombosis

• Helpful in the evaluation of patients with
  intermediate clinical and scan probabilities for
  pulmonary emboli .
• Serial (6 over 2 weeks) studies were proven
  beneficial withholding anticoagulation Rx till Dx
  of DVT was reached.

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Pulmonary angiography

• The Gold standard for diagnosis
• Invasive test
• Mortality of the procedure is less than 0.5
  percent
• Morbidity occurs in about 5 percent, usually
  related to catheter insertion or contrast
  reactions

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Helical CT scanning

• Detection of emboli in proximal pulmonary
  arteries is easier than in segmental arteries.
• Limited ability to detect emboli beyond segmental
  arteries.
• These small clots may not be very important
  physiologically, but their detection may be
  important as harbingers of future larger
  thromboemboli.

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CONCLUSION

• The combination of clinical assessment, lung
  scanning, D-dimer testing, and venous ultrasound
  will confirm or exclude acute pulmonary emboli in
  many patients.

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Thank You