Download - Acute Pulmonary Embolism Journal
![Page 1: Acute Pulmonary Embolism Journal](https://reader030.vdocuments.us/reader030/viewer/2022021218/577d2ac91a28ab4e1eaa1616/html5/thumbnails/1.jpg)
8/7/2019 Acute Pulmonary Embolism Journal
http://slidepdf.com/reader/full/acute-pulmonary-embolism-journal 1/23
Supervisor :
Alex Kusanto M.DPresentant :
Alvin Pradipta Jennifer Kurniawan
![Page 2: Acute Pulmonary Embolism Journal](https://reader030.vdocuments.us/reader030/viewer/2022021218/577d2ac91a28ab4e1eaa1616/html5/thumbnails/2.jpg)
8/7/2019 Acute Pulmonary Embolism Journal
http://slidepdf.com/reader/full/acute-pulmonary-embolism-journal 2/23
� Shock/sustained hypotension to mild
dyspnea� may be asymptomatic
![Page 3: Acute Pulmonary Embolism Journal](https://reader030.vdocuments.us/reader030/viewer/2022021218/577d2ac91a28ab4e1eaa1616/html5/thumbnails/3.jpg)
8/7/2019 Acute Pulmonary Embolism Journal
http://slidepdf.com/reader/full/acute-pulmonary-embolism-journal 3/23
� male sex� advanced age�
cancer� major surgery� immobilization because of an acute
medical illness� trauma
![Page 4: Acute Pulmonary Embolism Journal](https://reader030.vdocuments.us/reader030/viewer/2022021218/577d2ac91a28ab4e1eaa1616/html5/thumbnails/4.jpg)
8/7/2019 Acute Pulmonary Embolism Journal
http://slidepdf.com/reader/full/acute-pulmonary-embolism-journal 4/23
� suspected in all patients :new or worsening dyspneachest painsustained hypotension
without an alternative obvious
![Page 5: Acute Pulmonary Embolism Journal](https://reader030.vdocuments.us/reader030/viewer/2022021218/577d2ac91a28ab4e1eaa1616/html5/thumbnails/5.jpg)
8/7/2019 Acute Pulmonary Embolism Journal
http://slidepdf.com/reader/full/acute-pulmonary-embolism-journal 5/23
� Severity of clinical presentationpatient·s condition (hemodynamically stable orunstable)
![Page 6: Acute Pulmonary Embolism Journal](https://reader030.vdocuments.us/reader030/viewer/2022021218/577d2ac91a28ab4e1eaa1616/html5/thumbnails/6.jpg)
8/7/2019 Acute Pulmonary Embolism Journal
http://slidepdf.com/reader/full/acute-pulmonary-embolism-journal 6/23
� hemodynamic stabilityclinical probability assessment,d-dimer testingmultidetector computed tomography (CT)
ventilation²perfusion scanning
![Page 7: Acute Pulmonary Embolism Journal](https://reader030.vdocuments.us/reader030/viewer/2022021218/577d2ac91a28ab4e1eaa1616/html5/thumbnails/7.jpg)
8/7/2019 Acute Pulmonary Embolism Journal
http://slidepdf.com/reader/full/acute-pulmonary-embolism-journal 7/23
� specificity of >> d-dimer level is reducedin
patients with cancerpregnant womenhospitalizedelderly patients
![Page 8: Acute Pulmonary Embolism Journal](https://reader030.vdocuments.us/reader030/viewer/2022021218/577d2ac91a28ab4e1eaa1616/html5/thumbnails/8.jpg)
8/7/2019 Acute Pulmonary Embolism Journal
http://slidepdf.com/reader/full/acute-pulmonary-embolism-journal 8/23
H D stable patientsLow/intermediate clin probNormal d-dimer testing
if anticoagulant treatment is not givenestimated 3-month risk of thromboembolism 0.14%
unnecessaryfurtherinvestigation
![Page 9: Acute Pulmonary Embolism Journal](https://reader030.vdocuments.us/reader030/viewer/2022021218/577d2ac91a28ab4e1eaa1616/html5/thumbnails/9.jpg)
8/7/2019 Acute Pulmonary Embolism Journal
http://slidepdf.com/reader/full/acute-pulmonary-embolism-journal 9/23
� 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
![Page 10: Acute Pulmonary Embolism Journal](https://reader030.vdocuments.us/reader030/viewer/2022021218/577d2ac91a28ab4e1eaa1616/html5/thumbnails/10.jpg)
8/7/2019 Acute Pulmonary Embolism Journal
http://slidepdf.com/reader/full/acute-pulmonary-embolism-journal 10/23
� 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
![Page 11: Acute Pulmonary Embolism Journal](https://reader030.vdocuments.us/reader030/viewer/2022021218/577d2ac91a28ab4e1eaa1616/html5/thumbnails/11.jpg)
8/7/2019 Acute Pulmonary Embolism Journal
http://slidepdf.com/reader/full/acute-pulmonary-embolism-journal 11/23
![Page 12: Acute Pulmonary Embolism Journal](https://reader030.vdocuments.us/reader030/viewer/2022021218/577d2ac91a28ab4e1eaa1616/html5/thumbnails/12.jpg)
8/7/2019 Acute Pulmonary Embolism Journal
http://slidepdf.com/reader/full/acute-pulmonary-embolism-journal 12/23
� 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
![Page 13: Acute Pulmonary Embolism Journal](https://reader030.vdocuments.us/reader030/viewer/2022021218/577d2ac91a28ab4e1eaa1616/html5/thumbnails/13.jpg)
8/7/2019 Acute Pulmonary Embolism Journal
http://slidepdf.com/reader/full/acute-pulmonary-embolism-journal 13/23
� should be done promptly� Based on clinical features and markers of
myocardial dysfunction or injury
![Page 14: Acute Pulmonary Embolism Journal](https://reader030.vdocuments.us/reader030/viewer/2022021218/577d2ac91a28ab4e1eaa1616/html5/thumbnails/14.jpg)
8/7/2019 Acute Pulmonary Embolism Journal
http://slidepdf.com/reader/full/acute-pulmonary-embolism-journal 14/23
![Page 15: Acute Pulmonary Embolism Journal](https://reader030.vdocuments.us/reader030/viewer/2022021218/577d2ac91a28ab4e1eaa1616/html5/thumbnails/15.jpg)
8/7/2019 Acute Pulmonary Embolism Journal
http://slidepdf.com/reader/full/acute-pulmonary-embolism-journal 15/23
� International Cooperative PulmonaryEmbolism Registry death rate
hemodynamically unstable 58%hemodynamically stable 15%
![Page 16: Acute Pulmonary Embolism Journal](https://reader030.vdocuments.us/reader030/viewer/2022021218/577d2ac91a28ab4e1eaa1616/html5/thumbnails/16.jpg)
8/7/2019 Acute Pulmonary Embolism Journal
http://slidepdf.com/reader/full/acute-pulmonary-embolism-journal 16/23
� ECG Right ventricular dysfunctionincreased mortality
![Page 17: Acute Pulmonary Embolism Journal](https://reader030.vdocuments.us/reader030/viewer/2022021218/577d2ac91a28ab4e1eaa1616/html5/thumbnails/17.jpg)
8/7/2019 Acute Pulmonary Embolism Journal
http://slidepdf.com/reader/full/acute-pulmonary-embolism-journal 17/23
![Page 18: Acute Pulmonary Embolism Journal](https://reader030.vdocuments.us/reader030/viewer/2022021218/577d2ac91a28ab4e1eaa1616/html5/thumbnails/18.jpg)
8/7/2019 Acute Pulmonary Embolism Journal
http://slidepdf.com/reader/full/acute-pulmonary-embolism-journal 18/23
� Acute pulmonary embolism requiresinitial shortterm therapy
![Page 19: Acute Pulmonary Embolism Journal](https://reader030.vdocuments.us/reader030/viewer/2022021218/577d2ac91a28ab4e1eaa1616/html5/thumbnails/19.jpg)
8/7/2019 Acute Pulmonary Embolism Journal
http://slidepdf.com/reader/full/acute-pulmonary-embolism-journal 19/23
� 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
![Page 20: Acute Pulmonary Embolism Journal](https://reader030.vdocuments.us/reader030/viewer/2022021218/577d2ac91a28ab4e1eaa1616/html5/thumbnails/20.jpg)
8/7/2019 Acute Pulmonary Embolism Journal
http://slidepdf.com/reader/full/acute-pulmonary-embolism-journal 20/23
� 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
![Page 21: Acute Pulmonary Embolism Journal](https://reader030.vdocuments.us/reader030/viewer/2022021218/577d2ac91a28ab4e1eaa1616/html5/thumbnails/21.jpg)
8/7/2019 Acute Pulmonary Embolism Journal
http://slidepdf.com/reader/full/acute-pulmonary-embolism-journal 21/23
� 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)
![Page 22: Acute Pulmonary Embolism Journal](https://reader030.vdocuments.us/reader030/viewer/2022021218/577d2ac91a28ab4e1eaa1616/html5/thumbnails/22.jpg)
8/7/2019 Acute Pulmonary Embolism Journal
http://slidepdf.com/reader/full/acute-pulmonary-embolism-journal 22/23
� The risk of recurrent pulmonaryembolism
< 1% per year (receiving anticoagulant therapy)2 to 10% per year (after the discontinuation of such therapy)
![Page 23: Acute Pulmonary Embolism Journal](https://reader030.vdocuments.us/reader030/viewer/2022021218/577d2ac91a28ab4e1eaa1616/html5/thumbnails/23.jpg)
8/7/2019 Acute Pulmonary Embolism Journal
http://slidepdf.com/reader/full/acute-pulmonary-embolism-journal 23/23