Pulmonary embolism

Pulmonary Embolism in a nutshell

1. PULMONARY EMBOLISM Dr.Partha Das MEM,PGY2 Fortis Hospital, Kolkata 08/04/2016

2. STATISTICS (INDIAN SCENARIO) Overall, the annual incidence of PE ranges between 23 and 69 cases per 100,000 population  Responsible for up to 15% of all in-hospital deaths Accounts for 20 to 30% of deaths a/w pregnancy & delivery Average case fatality rate within 2 weeks of Δ of ~ 11 % Roughly accounting for at least 100,000 deaths each year Ref : indian heartjournal.com/ihj09/sep_oct_09/467-469.html

3. DEFINITION Refers to the obstruction of the pulmonary artery or one of its branches by a thrombus (or thrombi) that originates somewhere in the venous system or in the right side of the heart

4. PATHOPHYSIOLOGY Embolization Impaired gaseous exchange Increased pulmonary vascular resistance Increased airway resistance Decreased pulmonary compliance

5. Contd … As pulmonary vascular resistance↑, RV wall tension ↑ & causes further RV dilation & dysfunction ↓ ↑ RV wall tension also compresses the RCA ↓ ↓ subendocardial perfusion & limits myocardial oxygen supply ↓ Provokes MI → eventually circulatory collapse & death may ensue Ref : Harrison’s Principles of Internal Medicine, 18 th Ed

6. PREDISPOSING FACTORS Malignancy Prolonged bed rest Long-haul air travel Obesity COPD Systemic arterial HTN Smoking OCPs Pregnancy Surgery & trauma Post menopausal hormone replacement Thrombophilia, AF

7. HEREDITARY FACTORS Antithrombin III deficiency Protein C deficiency Protein S deficiency Factor V Leiden Plasminogen abnormality Fibrinogen abnormality Resistance to activated Protein C

8. VIRCHOW’S TRIAD

9. CLINICAL FEATURES Dyspnoea (m/c) Pleuritic chest pain (sudden & sharp) Substernal chest pain Cough Fever Hemoptysis Syncope Unilateral leg pain (signs of DVT) Diaphoresis Tachycardia, Tachypnoea Hypoxemia (paO2 < 8ommHg ) S 3 or S 4 gallop/cardiac murmur

10. Well’s Score For PE HR > 100 1.5 Hemoptysis 1 H/o previous TE 1.5 Active malignancy 1 Signs of DVT 3 Risk for PE >6 = High risk 2-6 = Moderate risk <2 = Low risk

11. PE Severity Index (PESI) Predictors Points Age +1 per year Male sex +10 Heart Failure +10 Chronic Lung disease +10 Art. O 2 sat. <90 % +20 Pulse >110bpm +20 RR>30/min +20 T˚<36˚C/96.8˚F +20 Cancer +30 SBP<100mmHg +30 Altered mentation +60

12. Contd… Score Risk Class <65 I 66-85 II 86-105 III 106-125 IV >125 V *Low prognostic risk is defined as ≤ 85 points

13. PE R/O Criteria (PERC) Age < 50 years HR < 100 bpm S p O 2 >95% in R/A No Hemoptysis No exogenous Estrogen use No previous TE No trauma/Surgery requiring hospitalization (in 4 weeks) No U/L leg swelling

14. DIAGNOSTIC FINDINGS Chest X Ray Radiographic signs include:- Fleishner sign : enlarged pulmonary artery (20%) Hampton hump :  peripheral wedge of airspace opacity and implies lung infarction (20%) Westermark's sign :  regional oligaemia and highest positive predictive value (10%) Pleural effusion  (35%) Knuckle sign   Ref : http://radiopaedia.org/articles/pulmonary-embolism

15. Contd… ECG Sinus tachycardia  –  m/c abnormality Complete or incomplete RBBB –  a/w ↑ mortality RV strain pattern –  T wave ↓ in the right precordial leads (V1-4) ± the inferior leads Right axis deviation Right atrial enlargement (P pulmonale ) – peaked P wave in lead II > 2.5 mm in height Atrial Tachyarrhythmias –  AF, Flutter Non specific ST-segment & T wave changes

16. Contd… CT Pulmonary Angiography (CTPA) filling defects within the pulmonary vasculature with acute pulmonary emboli When observed in the axial plane this has been described as the polo mint sign

17. Contd…

18. Other Investigations :- ECHO - It helps to detect RV enlargement & RWMA a/w PTE ( McConnell’s sign - hypokinesia of RV free wall with normal motion of RV apex is best known indirect sign of PE ) ABG - ↓ P a O 2 D- Dimer assay NT Pro BNP V/Q Scan Venous USG & Impedence Plethysmography Contrast enhanced Helical CT Lung

19. Diagnostic Approach

20. Management Provide O 2 by cannula/mask/ventilator – as indicated Elevate head-end of bed Elevate lower extremities if DVT is present Morphine to manage pain & anxiety (avoid in case of severe Hypotension) Inj. Heparin 10,000 U i /v bolus followed by 5000 U i /v 6 hourly charged in 200 ml N/S LMWH (Enoxaparin 1mg/kg BD s/c) Dopamine or Dobutamine infusion to treat hypotension & shock

21. Different LMWH in use Name Treatment Dose Enoxaparin 1 mg/kg twice daily (approved as an inpatient or outpatient dose), or 1.5 mg/kg once daily (inpatient dose only) Dalteparin 100 units/kg twice daily, or 200 units/kg once daily Tinzaparin 175 units/kg once daily

22. Pulmonary Embolectomy Emergency surgical removal of emboli which are blocking blood circulation & causing necrosis

23. Vena Cava Filter Type of vascular filter, a medical device that is implanted into the inferior vena cava to presumably prevent life-threatening pulmonary emboli

24. Prevention Leg exercises (Dorsiflexion of feet) Frequent position changes Ambulation Intermittent pneumatic leg compression devices Anti embolism stockings Tab.Warfarin 5mg BD x 3-4 weeks & then can be tapered to keep INR @ 2.5-3

25. REFERENCES Tintinalli’s Emergency Medicine e-Book 6 th Edition Harrison’s Principles of Internal Medicine 18 th Edition European Heart Journal, 2014 Kapoor VK. Venous thromboembolism in India. The National Medical Journal. 2010;23(4):193-95 . European Heart Journal Advance Access published August 29, 2014 radiopaedia.org/articles/pulmonary-embolism