venous thrombosis & pul.embolism : prof.dr. muhammad akbar chaudhary m.r.c.p. (u.k.) f.r.c.p....

VENOUS THROMBOSIS & PUL.EMBOLISM :

PROF.DR. MUHAMMAD AKBAR CHAUDHARYM.R.C.P. (U.K.) F.R.C.P. (E)F.R.C.P. (LONDON) F.A.C.C

DESIGNED AT A.V. DEPT F.J.M.C. BY RABIA KAZMI

VENOUS THROMBOSIS & PUL. EMBOLISM :RISK FACTORS : Immobility Age > 40 years Previous H/O D.V.T Varicose veins Obesity Malignant diseases Pregnancy Puerperium Oral contraceptives

Surgery Trauma Myocardial infarction Heart failure Polycythemia Thrombocythemia Connective tissue disease Congenital coagulation disorders

VENOUS THROMBOSIS & PUL. EMBOLISM :(cont)

RISK FACTORS OF VENOUS THROMBOEMBOLISM

PULMONARY EMBOLISM ;

Acute Chronic

MinorMassive

PULM. EMBOLISM :

PRESENTATION BY THREE CLINICAL SYNDROMES ;

1) PULM. INFARCTION/OR HAEMORRHAGE; Most common presentation ( >50% of

patients of pulm. embolism ), Abrupt pleuritic chest pain with or without dyspnea is classic symptom, Haemoptysis occurs in minority of patients.

ON EXAMINATION:

Patient has tachypnea No signs of Rt heart failure. Examination

of lungs shows rales, wheeze, pleural effusion & may be pleural rub, D.V.T evidence is rare

D.D : Viral & Bacterial pneumonitis

2) ACUTE COR-PULMONALE : Presentation is dramatic, It occurs when pulm.

embolism is massive to obstruct 60-75% of pulm. circulation. In response to Ac pulm. embolism, there is increased C. O & increased R.V systolic pressure to overcome increased resistance in pulm. circulation, The normal Rt ventricle can acutely increase its systolic pressure to about 50- 60 mmHg, Acute increase in pressure beyond this level causes Rt V dilatation & failure, decrease C.O.P, hypotension & cardiac arrest

patient presents with: Acute dyspnea, syncopy & cardiac arrest

PULMONARY EMBOLISM ;

PULMONARY EMBOLISM

ACUTE CORPULMONALE ON EXAMINATION There is tachypnea, tachycardia and hypotension,

signs of acute R.V. failure Lungs are clear D.V.T. may be present

D/ DIAGNOSIS Acute myocardial infarction Hypovolemia sepsis

PULMONARY EMBOLISM

3.) ACUTE UNEXPLAINED DYSPNEA Diagnosis most difficult with sub-massive Pul.

Embolism, who do not develop pul. Infarction E.C.G. & X-ray chest may be normal

D.V.T. may be present Only physical signs may be tachyapnea,

tachycardia & anxiety

D.D L.V.F Pneumonia Hyperventilation syndrome

CLINICAL DIFFERENCE BETWEEN THE VARIOUS PRESENTATIONS OF PULMONARY EMBOLISM

Acute minor

Acute major Chronic

Dyspnoea Mild Severe Chronic, progressive

Chest pain Pleuritic Acute, dull, central

Exertional, dull, central

Tachycardia Mild Usually marked

Variable

Blood pressure

Normal low Normal until late

Cyanosis No Common Common

Odema No Not acutely Common

CLINICAL DIFFERENCE BETWEEN THE VARIOUS PRESENTATIONS OF PULMONARY EMBOLISM (cont)

Acute minor Acute major Chronic

Jugular venous pressure

Normal Raised Raised

Heart sounds Normal S3 S3,S4, P2+

Chest Radiology

Often normal Usually abnormal

Abnormal

ECG Usually normal Usually abnormal

Abnormal

Systolic pulmonary artery pressure

Normal 30-50 mm Hg >70 mm Hg

Pulmonary embolism

InvestigationsX-ray chestE.C.GArterial blood gasesVentilation/perfusion lung scanPul. AngiographyVenography Investigations for malignancy

Pulmonary embolism

TreatmentProphylaxisTreatment of D.V.T. & minor P.ETreatment of large & massive

P.E.

ETIOLOGY OF CHRONIC COR-PULMONALE MECHANISIM OF PULMONARY HYPERTENSION

1. Hypoxic vasoconstrictionA. Chronic bronchitis and emphysema, cystic

fibrosis

B. Chronic hypoventilation

1. Obesity

2. Sleepapnea

3. Neuromuscular disease

4. Chest wall dysfunction

C. High-altitude dwelling and chronic mountain sickness (Monge’s Disease)

2. Occlusion of pulmonary vascular bedA. Pulmonary thromboembolism, parastic ova,

tumor emboli

B. Primary pulmonary hypertension

C. Pulmonary venocclusive disease

D. Fibrosing mediastinitis, mediastinal tumor

E. Pulmonary angitis from systemic disease

1. Collagen vascular diseases

2. Drug-induced lung diseases

3. Necrotizing and granulomatous arteries

3. Parenchymal disease with loss of vascular surface area

A. Bullous emphysema, ά 1 antiproteinase deficiency

B. Diffuse bronchiectasis, cystic fibrosisC. Diffuse interstitial disease1. Pneumoconioses 2. Sarcoid, idiopathic, pulmonary fibrosis,

histiocytosis X3.Tuberculosis,chronic fungal infection 4. ARDS5. Collagen vascular disease (immune lung disease)6. Hypersensitivity pneumonitis