PULMONARY EMBOLISM.pptx and its management

Very quick review on the pulmonary embolism

1. CASE PRESENTATION: A 59 years ol d femal e , K/C of diabetes, hypertension , presented to ER department with complain of sudden onset of shortness of breath , palpitations and severe chest pain for 1 day, not relieved by medications, associated with Fever 99°F.She travelled by Airplane ,just came Pakistan to meet her Grand children 2 days back. She was on HRT ( Estrogens ),Her total abdominal hystrectomy was done 1 year back.There were no such symptoms since then. Her Baseline investigations were done, CBS was normal,TROP I – ve , her ECG showed sinus Tachycardia without any ST-T changes or T wave inversions. Chest X ray was Normal.

2. EXAMINATION: VITALS: BP---90 /74 mmHg Respiratory rate: 36/min Pulse rate: 128 bpm Sp02: 8 2 % AT RA CVS: S1+S2+0 RESP: NVB + B/L coarse crepitations at bases GCS 12 /15 B/L pedal e dema was present / No Raised JVP

3. PLAN OF ACTION …. Diagnosis??? Management??? Initial/long Term Follow up???

4. PULMONARY EMBOLISM Presented by : Sheeza saeed House Officer, Cardiology

5. DEFINITION : OBSTRUCTION OF PULMONARY ARTERY OR ONE OF ITS BRANCHES , BY A THROMBUS ( OR THROMBI), ORIGINATES SOMEWHERE IN THE VENOUS SYSTEM. MOSTLY FROM THE LOWER LIMBS (DVT) A POTENTIAL CARDIOVASCULAR EMERGENCY DIFFERENT FORMS OF EMBOLI: COULD BE A BLOOD CLOT, AIR, FAT,AMNIOTIC FLUID AND SEPTIC AS WELL

6. EPIDEMIOLOGY: Venous thromboembolism clinically presents as DVT or PE is, globally the 3 rd most frequent acute cardiovascular syndrome behind myocardial infarction and stroke. Annual incidence rate for pulmonary embolism ranges from 39-115 per 100,000 population. PE may cause < 300,000 deaths per year in US, ranking high among the causes of cardiovascular mortality.

7. Pathophysiology....

8. Approach towards pulmonary Embolism History (Determine Risk Factors) Clinical assessment and making Diagnosis (Wells criteria/Predictive Value) Investigations High/Intermediate/Low Risk PE Management

9. RISK FACTORS :

10. SIGNS AND SYMPTOMS DYSOPNEA CHEST PAIN COUGH HAEMOPTYSIS SYNCOPE PRE-SYNCOPE HYPOXEMIA PAIN IN CALF OR THIGH HAEMODYNAMIC INSTABILIT OR SHOCK

11. Prediction of PE ?( pre-test probability)

12. INVESTIGATIONS : CHEST X-RAY ECG RV strain pattern- inversion of t wave in lead v1-v4 S1Q3T3 Pattern Incomplete or complete right bundle branch block Sinus tachycardia- in 40% patients Atrial arrhythmias/ atrial fibrillation Right axis deviation

13. Sinus tachycardia Simultaneous t wave inversions in v1-v4 and inferior leads

14. ECHOCARDIOGRAPHY:

15. PULMONARY EMBOLISM SEVERITY INDEX (PESI SCORE)

16. Treatment in acute phase: HEMODYNAMIC AND RESPIRATORY SUPPORT : 1)Oxygen therapy and ventilation 2) Medical treatment of acute right ventricular failure INITIAL ANTICOAGULATION P arenteral anticoagulation : sub-cutaneous weight adjusted bolus low molecular weight heparin (LMWH) ,fondaparinux or IV UF heparin 2 ) NON- V itamin k antagonists 3) Vitamin K antagonists

17. Non vitamin k antagonists / VKA: ORAL ANTICOAGULANTS Dabigatron not recommended in patients with CrCL < 30ml/ min Edoxaban should be given at a dose of 30 mg once daily in patients with Crcl of 15-50 ml/ min and not recommended in patients with Crcl <15 Rivaroxaban and Apixiban are to be used with caution in the patients CrCl 25-29 ml/min and their use is not recommended in patients with Crcl <15 ml/ min When VKAs( WARFARIN) are used, anticoagulation with UFH , LMWH or fondaparinaux should be contined in parallel with oral anticoagulant for > 5 days and until INR has been 2-3 for 2 consecutive days.

18. Reperfusion therapy: (Thrombolysis) Systemic thrombolysis Percutaneous catheter directed treatment Surgical E mbolectomy Vena Caval FILTERS- Prevent clots from reaching p ulmonary circulation.

19. INDICATIONS FOR THROMBOLYSIS : HEMODYNAMIC IN STABILITY HYPOXIA ON 100% OXYGEN RV DYSFUNCTION GREATEST BENEFIT = WITHIN 48 HOURS UN SUCCESSFUL > 36 HOURS CAN BE USEFUL IN 6-14 DAYS

20. Contraindications for Thrombolytic Therapy :

21. Discharge Criteria / Hospitalization

22. In cancer patients:

23. In pregnant women :

24. Follow up after acute pulmonary embolism : at 3-6 Months

25. TAKE HOME MESSAGE: ALWAYS KEEP SUSPICION OF PULMONARY EMBOLISM HIGH IN ACUTE SETTINGS THINK OF PE IN ANY PATIENT PRESENTING WITH CHEST PAIN OR SOB SPECIALLY IF ECG AND CHEST X RAY ARE NORMAL, AND STILL patient IS HYPOXIC ITS IMP TO RULE OUT PE IN PT, WITH CHEST PAIN, ELEVATED CARDIAC TROP AND NORMAL ANGIOGRAPHIC FINDINGS . CTPA I S IMAGING OF CHOICE TO DIAGONOSE PE. START ANTI-COAGULATION IN high risk and intermediate risk, with ongoing investigations NOACS ARE PREFERRED over VKA for oral long term use . NOACS and warfarin are not used in pregnancy . THROMBOLYSIS SHOULD BE DONE in all HIGH RISK PE patients , until unless contraindicated .