Case Report Case Report PneumologyPneumology

Dr. David TranDr. David Tran

A&E, FVHospitalA&E, FVHospital

Medical meeting September 28Medical meeting September 28thth, , 20112011

Female 26 years oldFemale 26 years old Consults A&E on September 18Consults A&E on September 18thth for chest pain, cough for chest pain, cough

with small amount of blood in the sputum during the with small amount of blood in the sputum during the

night.night.

Complains about shortness of breath Complains about shortness of breath for 2 or 3 days.for 2 or 3 days.

She mentions a traffic accident 3 weeks ago without She mentions a traffic accident 3 weeks ago without

thoracic trauma thoracic trauma (just a small trauma at the R knee)(just a small trauma at the R knee)

She has been in close contact with a acute case of She has been in close contact with a acute case of

tuberculosis a few months ago.tuberculosis a few months ago.

No past medical history, she smokes 20 cig./day.No past medical history, she smokes 20 cig./day.

Physical examinationPhysical examination Pulse 58/min, BP 100/60, RR 18/min., SpO2 100% Pulse 58/min, BP 100/60, RR 18/min., SpO2 100%

(air), EVA 4/10, Glasgow 15.(air), EVA 4/10, Glasgow 15.

Auscultation shows slight decreased mumure in the Auscultation shows slight decreased mumure in the

right base of the thorax, no rales, no crackles.right base of the thorax, no rales, no crackles.

There is no sign of chest trauma, the ribs are not There is no sign of chest trauma, the ribs are not

painful at palpation, the abdomen is soft.painful at palpation, the abdomen is soft.

The legs are not swollen, there is a splint on the The legs are not swollen, there is a splint on the

right knee no pain at the right calf, no Homans sign.right knee no pain at the right calf, no Homans sign.

ECGECG

Chest Xray Chest Xray

Hematological resultsHematological results

Biochemical resultsBiochemical results

D. Dimeres resultsD. Dimeres results

After discussion with the After discussion with the patientpatient

She informed us that she had bed rest for She informed us that she had bed rest for almost 3 weeks after her accident due to almost 3 weeks after her accident due to the immobilization of the right leg in a the immobilization of the right leg in a splint.splint.

She received no anticoagulation during She received no anticoagulation during this time.this time.

She has no personnal or familial history of She has no personnal or familial history of thrombosis.thrombosis.

SShe he uses to smokeuses to smoke about 20 cig./day about 20 cig./day and and takes oral contraceptive pils for 2 years.takes oral contraceptive pils for 2 years.

Angio CT scanner thoraxAngio CT scanner thorax

AngioCT scanner of the AngioCT scanner of the thoraxthorax

TreatmentTreatment

Perfalgan 1g + Morphin 3mg (scanner)Perfalgan 1g + Morphin 3mg (scanner) Lovenox 0.6ml (60mg) s/cut x 2 per dayLovenox 0.6ml (60mg) s/cut x 2 per day Start Coumadine 4mg the day afterStart Coumadine 4mg the day after Check INR 48h to 72h after the onset of anti-Check INR 48h to 72h after the onset of anti-

vitK treatment.vitK treatment. Contention socksContention socks Hospitalized in medical ward (Dr Thai, Hospitalized in medical ward (Dr Thai,

cardiologist) cardiologist)

DVT & Pulmonary DVT & Pulmonary EmbolismEmbolism

117 cases / 100.000 persons in USA 117 cases / 100.000 persons in USA (increases with (increases with

the age)the age)

Importance of risk factors Importance of risk factors (immobilization, (immobilization,

contraceptive drugs, flight travel, familial or personal contraceptive drugs, flight travel, familial or personal

past history)past history)

Most clinical PE originate from a proximal DVT Most clinical PE originate from a proximal DVT

from the legs above the knee from the legs above the knee ((popliteal, femoral or popliteal, femoral or

iliac veiniliac vein))

As many patients have intermediate probability As many patients have intermediate probability

of venous thrombosis, clinical jugement is still of venous thrombosis, clinical jugement is still

the cornerstone of the diagnosis.the cornerstone of the diagnosis.

Risk factorsRisk factors

D-Dimer testsD-Dimer tests

D-DimerD-Dimer are very sensitive but have a very low are very sensitive but have a very low

specificity specificity (Good negative predictive value)(Good negative predictive value)

D-Dimer D-Dimer can rule out the diagnosis of PE in only 5% of can rule out the diagnosis of PE in only 5% of

patients aged > 80 yearspatients aged > 80 years (60% in young patients < 40 years (60% in young patients < 40 years

old)old)

Low risk of DVT assessment by validated prediction Low risk of DVT assessment by validated prediction

score and a negative score and a negative D-dimer D-dimer test test (Latex agglutination)(Latex agglutination) is is

deemed to rule out the diagnosis of DVT.deemed to rule out the diagnosis of DVT.

D-DimerD-Dimer positive result does not raise the likelihood of positive result does not raise the likelihood of

DVT and has therefore limited clinical value alone. DVT and has therefore limited clinical value alone.

Clinical probability score Clinical probability score ((Geneve ScoreGeneve Score))

Wells score of probability for Wells score of probability for PEPE

Assess clinical Assess clinical probability probability

Use of d-dimer and angio-CT for Use of d-dimer and angio-CT for the diagnosis of Pulmonary the diagnosis of Pulmonary EmbolismEmbolism

Decisional algorithm for Decisional algorithm for the diagnosis of PE the diagnosis of PE

CT pulmonary CT pulmonary angiographyangiography(Se 83%, Sp 96%)(Se 83%, Sp 96%)

Principle of PE Principle of PE treatmenttreatment

Immediate full anticoagulation is mandatory for all Immediate full anticoagulation is mandatory for all patients suspected of having have DVT or pulmonary patients suspected of having have DVT or pulmonary embolism. embolism.

Diagnostic investigations should not delay empirical Diagnostic investigations should not delay empirical anticoagulant therapy. anticoagulant therapy.

Current guidelines recommend starting unfractionated Current guidelines recommend starting unfractionated heparin (UFH), low–molecular weight heparin (LMWH), heparin (UFH), low–molecular weight heparin (LMWH), or fondaparinux (all grade 1A) in addition to an oral or fondaparinux (all grade 1A) in addition to an oral anticoagulant (warfarin) at the time of diagnosis anticoagulant (warfarin) at the time of diagnosis

Discontinue UFH, LMWH only after the international Discontinue UFH, LMWH only after the international normalized ratio (INR) is 2.0 for at least 24 hours, but normalized ratio (INR) is 2.0 for at least 24 hours, but no sooner than 5 days after warfarin therapy has no sooner than 5 days after warfarin therapy has been started (grade 1C recommendation). been started (grade 1C recommendation).

Curative TreatmentCurative Treatment

Low molecular weight heparin (LMWH)Low molecular weight heparin (LMWH)

LOVENOX 0.1ml/10Kg LOVENOX 0.1ml/10Kg sub-cut twice a daysub-cut twice a day

Early relay with anti-vitamin K by mouthEarly relay with anti-vitamin K by mouth

INR after 48-72h of treatmentINR after 48-72h of treatment

Stop Heparin when INR 2< <4 at 2 timesStop Heparin when INR 2< <4 at 2 times Duration of efficient anticoagulationDuration of efficient anticoagulation

minimum 3 to 6 months minimum 3 to 6 months (according persistent(according persistent

risk factorsrisk factors))

Think to Pulmonary Think to Pulmonary Embolism!Embolism!