Pulmonary Thromboembolism | Jindal Chest Clinic

Pulmonary Thromboembolism is a blood clot that originates in a deep vein in the leg and travels to the lung, blocking blood flow to an artery in the lung. A clot in a different vein is an uncommon condition known as deep vein thrombosis (DVT). For more information, please contact us: 9779030507.

1. Pulmonary Thromboembolism

2. Pulmonary Thromboembolism Migration of a clot (or clots) from systemic veins (venous thrombosis) to the pulmonary vascular bed Incidence: Approx. 500,000/year in USA (about 10% of 5 million venous thrombosis episodes) Approx. 10% (i.e. 50,000) are fatal

3. Characteristics of P.E. Source: Deep veins of legs Pelvic veins (women) Upper extremity Type: Bland Septic Nature: Blood, Air Others : Tissue , fibres , liquid droplets , fat, amniotic fluid, parasites

4. Venous Thrombosis Virchow’s Triad Stasis Hypercoagulability Vessel wall injury Deposition of platelets, fibrin and red cells on venous valves/ sinuses

5. Thromboembolic Risk Factors Hereditary Thrombophilias Protein C deficiency Protein S deficiency Antithrombin III deficiency Factor V Leiden mutation Prothrombin 20210 G/A variation Hyperhomocysteinaemia Dysfibrinogenaemia Familial plasminogen deficiency

6. B. Acquired Predispositions Medical Prior VTE Advanced age Malignancy CHF, CCR Stroke, Neph . syn Oestrogen therapy Obesity, IBD Immobilization APLA syndrome Lupus anticoagulant Behcet’s syndrome Surgical Major abdominal or N.S. procedures under GA for >30 minutes Hip, knee arthroplasty Knee arthroscopy Hip fracture Major trauma Spinal cord injury Open prostatectomy Pregnancy and post partum period

7. Air Embolism Accidental introduction during I.V. injections Haemodialysis C.V.P. lines Artificial pneumothorax or pneumomediastinum

8. Factors influencing effects 1. Emboli related: Size of vessel Nature of emboli Extent of pulm vasc bed occlusion 2. Patient related: Preexisting cardiopulm status 3. Secondary effects: Hypoxaemia Release of neuro humoral mediators Reflex stimulation

9. Physiological Effects 1. Respiratory Increased dead space Hyperventilation Bronchiolar narrowing 2. Circulatory Systemic hypotension Pulmonary hypertension Pulmonary infarction 3. V/Q imbalances Venous admixture

10. Diagnosis of DVT Clinical features Contrast venography Impedance plethysmography Real time ultrasonography M.R. venography Radio labeled antibody imaging

11. Diagnosis of PTE Clinical S & S Lab. data : TLC, S. enzymes, D-dimer ECG, Echocardiography Art. blood gases: Dead space & A-a DO 2 Chest radiography V/Q scanning (Nuclear) CT, spiral CT, MRI, Angiography ( conventional angiography)

12. Signs and Symptoms (P.E.) Massive (%) Submassive (%) No cardiac/ pulm disease (%) Dyspnoea 85 82 73 Chest pain 64 85 66 Cough 53 52 37 Haemoptysis 23 40 13 Tachypnoea 95 87 70 Tachycardia (>100/min) 48 38 30 Loud P 2 58 45 23 Rales 57 60 51 Phlebitis 36 26 11

13. Electrocardiography Sinus tachycardia T wave inversion in leads V1-4 S1Q3T3 pattern New RBBB New onset atrial flutter

14. Radiological signs of PE   Common Atelectasis Raised hemidiaphragm Focal infiltrate Small pleural effusion Rare Focal oligemia ( Westermark’s sign )

15. CT Angiography

16. D-Dimer Assay Follows fibrinolysis of clot – may rise within 1 hour of PTE, circulating half life about 4-6 hours Method: ELISA (takes 2-4 hours) Rapid methods – Need standardization

17. Radionucleide Scanning Simple and safe, if available Technetium 99m labelled microspheres (3-4 mCi of Tc 99m ) Intravenous injection – supine position Counting on gamma camera Different projections Matching with freshly obtained CXR; ventilation scanning (if mismatched)

18. Ventilation – Perfusion Scan More useful if read along with clinical probability of PTE High probability scan highly predictive of PTE Normal or near normal scan virtually rules out PTE Low, indeterminate or intermediate probability scans (30% have PTE) need further tests

19. Management Prophylaxis Anticoagulation Heparin , Warfarin, LMWH Others : Hirudins , Synthetic thrombin inhibitors Thrombolysis Interventional radiological techniques: Clot lysis , disruption, removal Surgical methods

20. Thrombolytic agents Streptokinase Urokinase Recombinant tissue plasminogen activator ( rtPA )

21. Thrombolytic therapy -Contraindications Absolute : - Hemorrhagic stroke or stroke at anytime - Ischemic stroke in preceding six months - Central nervous system damage or neoplasm - Recent major trauma/surgery/head injury - Gastrointestinal bleeding within the last month; Known active bleeding Relative: - Transient ischemic attack in preceding six months - Oral anticoagulant therapy - Pregnancy or within one week postpartum - Traumatic resuscitation - Refractory hypertension (systolic blood pressure > 180 mmHg) -Advanced liver disease, Active peptic ulcer - Infective endocarditis

22. Anti-coagulation Heparin: Low mol wt heparin. Reduces progression of clot and risk of further embolization. Subcutaneous administration Given for 5 days. Oral agents: Warfarin Fondapernux Other agents Monitor INR

23. Recommendations for duration of anti-coagulation Thromboembolism Duration PE secondary to a transient (reversible) risk factor 3 months Unprovoked PE At least 3 months First episode of unprovoked PE and low risk of bleeding, and in whom stable Anticoagulation can be achieved   May be considered for long term anti-coagulation Second episode of unprovoked PE Long term anti-coagulation PE and cancer LMWH should be considered for the first 3 to 6 months. After this period, anti-coagulant therapy with VKA or LMWH should be continued indefinitely or until the cancer is cured.

24. Prevention of VTE Risk identification Low dose unfractionated heparin (5000 U, 8 or 12 hrs ) Low molecular weight heparin Pneumatic compressive devices Sodium warfarin

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