acute pulmonary embolism journal
TRANSCRIPT
8/7/2019 Acute Pulmonary Embolism Journal
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Supervisor :
Alex Kusanto M.DPresentant :
Alvin Pradipta Jennifer Kurniawan
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� Shock/sustained hypotension to mild
dyspnea� may be asymptomatic
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� male sex� advanced age�
cancer� major surgery� immobilization because of an acute
medical illness� trauma
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� suspected in all patients :new or worsening dyspneachest painsustained hypotension
without an alternative obvious
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� Severity of clinical presentationpatient·s condition (hemodynamically stable orunstable)
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� hemodynamic stabilityclinical probability assessment,d-dimer testingmultidetector computed tomography (CT)
ventilation²perfusion scanning
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� specificity of >> d-dimer level is reducedin
patients with cancerpregnant womenhospitalizedelderly patients
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H D stable patientsLow/intermediate clin probNormal d-dimer testing
if anticoagulant treatment is not givenestimated 3-month risk of thromboembolism 0.14%
unnecessaryfurtherinvestigation
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� If multidetector CT isnot availablerenal failure
allergy to contrast dye
� negative predictive value 97 %� diagnostic 30 to 50% of patients with
suspected pulmonary embolism
ventilation² perfusionscanning is analternative
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� hemodynamically unstablemultidetector CT should be performed 97 %sensitivity for detecting emboli in the mainpulmonary arteries
� If not available echocardiography
should be performed to confirm thepresence of right ventricular dysfunction
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� hemodynamically unstableShock , orSBP < 9 0 mm H gDrop in pressure of >40 mm H g>15 minutes (in the absence of new onsetarrhythmia, hypovolemia, and sepsis)
high clinical probabilityelevated d-dimer levelnegative findings on multidetector CT
venous ultrasonographyshould be considered
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� should be done promptly� Based on clinical features and markers of
myocardial dysfunction or injury
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� International Cooperative PulmonaryEmbolism Registry death rate
hemodynamically unstable 58%hemodynamically stable 15%
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� ECG Right ventricular dysfunctionincreased mortality
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� Acute pulmonary embolism requiresinitial shortterm therapy
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� LMW H
Enoxaparin (at a dose of 1 mg/kgBW , twicedaily)tinzaparin (1 7 5 U/kg once daily)
� Fondaparinux once daily5 mg, BW< 50 kg7
.5 mg 50<BW<100 kg10 mg BW>100 kg
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� Intravenous unfractionated heparininitial bolus dose (80 IU per kilogram or 5000 IU)followed by continuous infusion (usually starting
with 18 IU /kg/h)Target TT 1.5 to 2.5x normal value
�
LMWH &
F
ondaparinux excreted inkidneys
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� Mortality 6 0% in untreated patients� Reduced < 30% with prompt treatment
� Major contraindications to thrombolytictherapy
intracranial disease
Uncontrolled hypertensionrecent major surgery or trauma (within the past 3
weeks)
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� The risk of recurrent pulmonaryembolism
< 1% per year (receiving anticoagulant therapy)2 to 10% per year (after the discontinuation of such therapy)
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