a&e(vinayaka) “the great masquerader” pulmonary embolism dr. prakash mohanasundaram...
TRANSCRIPT
A&E(VINAYAKA)
“THE GREAT MASQUERADER”
PULMONARY EMBOLISM
Dr. Prakash Mohanasundaram EMERGENCY PHYSICIAN
A&E(VINAYAKA)
DEFINITION
A&E(VINAYAKA)
Triad:HypercoagulabilityStasis to flowVessel injury
A&E(VINAYAKA)
RISK FACTORSHYPERCOAGULABILITY
Malignancy Pregnancy Postpartum status(<4 wks) Estrogen Antiphospholipid
antibodies Genetic mutations Factor V Leiden
mutation Prothrombin gene
mutation Factor VIII mutations Protein C deficiency Protein S deficiency
VENOUS STASIS
Bed rest >48 hrs Cast or external fixator Recent hospitalisation Long distance
automobile or air travel
VESSEL INJURY
Recent surgery requiring endotracheal intubationRecent trauma requiring hospitalisation
A&E(VINAYAKA)
PATHOPHYSIOLOGY
EmbolizationPhysiologyRight ventricular dysfunction
A&E(VINAYAKA)
EMBOLIZATION
Proximal leg DVTCalf vein thrombiUpper extremity thrombosis
A&E(VINAYAKA)
PHYSIOLOGYIncreased pulmonary vascular resistance
Impaired gas exchange
Alveolar hyperventilation
Increased airway resistance
Decreased pulmonary compliance
A&E(VINAYAKA)
DEATH
“RIGHT VENTRICULAR DYSFUNCTION”
A&E(VINAYAKA)
Clinical Features Symptoms in Patients with Angio Proven PTE
Symptom Percent
Dyspnea 84Chest Pain, pleuritic 74Anxiety 59Cough 53Hemoptysis 30Sweating 27
Chest Pain, nonpleuritic 14Syncope 13
A&E(VINAYAKA)
Clinical Features
Signs with Angiographically Proven PE
Sign Percent
Tachypnea > 20/min 92Rales 58Accentuated S2 53Tachycardia >100/min 44Fever > 37.8 43Diaphoresis 36S3 or S4 gallop 34
Thrombophebitis 32Lower extremity edema 24
A&E(VINAYAKA)
Unexplained tachypnoea, tachycardia,
Hypoxia –Suspect PTE
A&E(VINAYAKA)
PRETEST PROBABILITY
A&E(VINAYAKA)
DIAGNOSING MODALITIES
NON IMAGING
D-Dimer ELISA ABG ECG
NON INVASIVE
CXR Venous
ultrasonography Chest CT Lung scanning MR Contrast
enhanced Echocardiography
INVASIVE
Pulmonary angiography (GOLD STANDARD)Contrast phlebography
A&E(VINAYAKA)
D-dimer TestFibrin split product
Circulating half-life of 4-6 hours
Positive assay > 500 ng/ml
Quantitative test have 80-85% sensitivity, and 93-100% negative predictive value
False Positives:
Pregnant Patients Post-partum < 1 weekMalignancy Surgery within 1 weekAdvanced age > 80 years SepsisHemmorrhage CVAAMI Collagen Vascular DiseasesHepatic Impairment
A&E(VINAYAKA)
ABG
HypoxemiaHypocarbia
“ LACK DIAGNOSTIC UTILITY IN PE ”
A&E(VINAYAKA)
ECG
Most Common Findings:
Tachycardia or nonspecific ST/T-wave changes
Acute cor pulmonale or right strain patterns
Tall peaked T-waves in lead II (P pulmonale)
Right axis deviation RBBB S1-Q3-T3 (occurs in only 20% of
PE patients)
Atrial fibrillation / Atrial flutter
A&E(VINAYAKA)
Chest X rayWestermark’s sign
focal oligemia / cut off sign
Hampton’s hump peripheral wedge shaped density above the diaphragm
Palla’s sign enlarged right descending pulmonary artery
ALMOST ALWAYS NORMAL CHEST X RAY
A&E(VINAYAKA)
WESTERMARK SIGN
A&E(VINAYAKA)
HAMPTON’S HUMP
A&E(VINAYAKA)
PALLA’S SIGN
A&E(VINAYAKA)
Venous Ultrasonography
Loss of vein compressibility½ of pts with PE have no imaging evidence of DVT
A&E(VINAYAKA)
Chest CTPrincipal imaging testNew generation multislice scanners locates thrombi in the fifth order branchesAlternative diagnosisPneumoniaEmphysemaPulmonary fibrosisPulmonary massAortic pathology
A&E(VINAYAKA)
V/Q SCAN
A&E(VINAYAKA)
NORMAL V/Q SCAN
A&E(VINAYAKA)
ABNORMAL V/Q SCAN
A&E(VINAYAKA)
MR contrast enhanced
Results similar compared with first generation CTAlso assesses right ventricular function
A&E(VINAYAKA)
Echocardiography
½ pts have normal echo
DD’s AMI Pericardial tamponade Aortic dissection PE complicated by right
heart failure
• Risk stratification MC CONNEL’s sign – MC CONNEL’s sign – right ventricular free right ventricular free wall hypokinesis with wall hypokinesis with normal right normal right ventricular apical ventricular apical motionmotion
A&E(VINAYAKA)
Pulmonary angiography(GOLD STANDARD)
Detect emboli as small as 1 to 2 mm
RESERVED FOR
1) Technically inadequate CT scans2) Scans performed on older machines3) Pts who will undergo interventions
A&E(VINAYAKA)
Pulmonary Embolus
Arrow indicates abrupt termination of a pulmonary artery.
Www.brighamrad.Harvard.edu/cases/bwh/images.
A&E(VINAYAKA)
A&E(VINAYAKA)
TREATMENT
A&E(VINAYAKA)
DICTUM“ABC”
A&E(VINAYAKA)
RISK STRATIFICATION
A&E(VINAYAKA)
TREATMENTPRIMARY
THERAPY
ThrombolysisEmbolectomy
ADJUNCTIVETHERAPY
O2Pain reliefDobutamine Caution – volume
overload
SECONDARY THERAPYAnticoagulationIVC filters
Pulmonarythromboendarterctomy
A&E(VINAYAKA)
SCENARIO
45 year male, case of OPC poisoning
Being treated with mechanical ventilation
Paralysed & sedated for 2 days
Develops sudden tachypnoea, tachycardia, hypotension & hypoxia
A&E(VINAYAKA)
WHAT IS YOUR LINE OF MANAGEMENT
A&E(VINAYAKA)
THROMBOLYSIS
Recombinant tPA 100 mg iv infusion over 2 hours
Streptokinase 250,000 U iv over 30 mins foll by 100,000 U/hr for 24 hrs
Urokinase 4,4OO U/kg iv over 10 mins foll by 4,000 U/kg/hr for 12 hrs
Alteplase 15 mg iv bolus foll by 2 hr infusion of
85 mg ( discontinue heparin during
infusion)
A&E(VINAYAKA)
SCENARIO
45 year male, A case of glioma
Underwent craniotomy & evacuation 2 days ago
Bed ridden for 2 days
Develops sudden tachypnoea, tachycardia, hypotension & hypoxia
A&E(VINAYAKA)
WHAT IS YOUR LINE OF MANAGEMENT
A&E(VINAYAKA)
EMBOLECTOMY
Indicated in pts with risk of thrombolysis
Surgical embolectomyCatheter embolectomy
A&E(VINAYAKA)
SCENARIO 45 year male, case of OPC poisoning
Being treated with mechanical ventilation
Paralysed & sedated for 2 days
Develops sudden tachypnoea & tachycardia
BP - Normal
A&E(VINAYAKA)
WHAT IS YOUR LINE OF MANAGEMENT
ECHO NORMAL
A&E(VINAYAKA)
Heparin / LMWH / Warfarin
Heparin 80 U/kg iv bolus foll by 18 U/kg/hr
Enoxaparin 1 mg/kg twice daily / 1.5 mg/kg daily
Tinzaparin 175 mg/kg OD
Fondaparinux <50 kg receive 5 mg, 50–100 kg patients receive 7.5 mg >100 kg receive 10 mg.
Warfarin – 2.5 to 10 mg Target INR – 2.0 TO 3.0
A&E(VINAYAKA)
IVC Filters
INDICATIONS
1) Active bleeding that precludes anticoagulation
2) Recurrent venous thrombosis despite intensive anticoagulation
A&E(VINAYAKA)
PREVENTION OF PULMONARY THROMBOEMBOLISM
A&E(VINAYAKA)
SUMMARY> 50 % pts with DVT are associated with PE
> 50 % cases do not have any signs or symptoms
Common presentation can be unexplained tachycardia, tachypnoea, hypoxemia or mere anxiety
Diagnosis and suspicion is purely clinical
Follow up with anticoagulants is must as there is a increased risk of recurrence
A&E(VINAYAKA)
A&E(VINAYAKA)