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Pulmonary embolism 2
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- 2. https://www.facebook.com/groups/1451610115129555/#!/groups/145 1610115129555/ Wellcome in ournew group ..... Dr.SAMIR EL ANSARY
- 3. Incidence • The trueincidence of PE is unknown and is suspected to be underestimated • It is estimated to be between 0.5% to 3% in the general population • Mortality from PE is estimated to be 0.1%
- 4. Risk Factors • Previousor current DVT • Immobilization • Surgery within the last 3 months • Stroke/paralysis • Central venous instrumentation within the last 3 months • Malignancy • CHF
- 5. Risk Factors • Autoimmunediseases • Air travel • Thrombophillias • In Women – Obesity (BMI ≥29) – Pregnancy – Heavy cigarette smoking (>25 cigarettes per day) – Hypertension
- 6. Presentation Dyspnea atrest or with exertion (73 %) Pleuritic pain (44 %) Cough (34 %) >2-pillow orthopnea (28 %) Calf or thigh pain (44 %) Calf or thigh swelling (41 %), Wheezing (21 %) Rapid onset of dyspnea within seconds (46 %) within minutes (26 %) • Tachypnea (54 %) • Tachycardia (24 %) • Rales (18 %), • Decreased breath sounds (17 %), • Accentuated pulmonic component of the second heart sound (15 %) • Jugular venous distension (14 %) Most Common Symptoms Most Common Signs
- 7. Clinical Decision Rules Modelsfor assessing clinical Probability of Pulmonary Embolism Well’s Criteria Geneva Score
- 8. Wells’ Score Clinical symptomsof DVT (leg swelling, pain with palpation) 3.0 Other diagnosis less likely than pulmonary embolism 3.0 Heart rate >100 1.5 Immobilization (≥3 days) or surgery in the previous four weeks 1.5 Previous DVT/PE 1.5 Hemoptysis 1.0 Malignancy 1.0 Traditional clinical probability assessment (Wells criteria) High >6.0 Moderate 2.0 to 6.0 Low <2.0 Simplified clinical probability assessment (Modified Wells criteria) PE likely >4.0 PE unlikely ≤4.0
- 9. Simplified Geneva Score VariableScore Age >65 1 Previous DVT or PE 1 Surgery or fracture within 1 month 1 Active malignancy 1 Unilateral lower limb pain 1 Hemoptysis 1 Pain on deep vein palpation of lower limb and unilateral edema 1 Heart rate 75 to 94 bpm 1 Heart rate greater than 94 bpm +1 Score of less than 2 is low probablility for PE, score of less than 2 plus a negative D- dimer results in a likelihood of PE of 3%
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- 11. D-Dimer Elevated inthrombosis, malignancy, pregnancy, elderly, hospitalized patients Role in low or moderate probability for PE Normal results can rule out PE Estimated 3 month risk of thromboembolism with negative D-dimer is 0.14% Role in high probability patients proceed to CT, Negative d-dimer can miss up to 15% of patients in this group
- 12. EKG in PulmonaryEmbolism Most commonly sinus tachycardia, with possible nonspecific ST/T wave changes Only 10% of patients can have the S1Q3T3 so not reliable Other EKG abnormalities including atrial arrhythmias, right bundle branch block, inferior Q-waves, and precordial T-wave inversion and ST-segment changes, are associated with a poor prognosis. S1Q3T3
- 13. Chest Radiography • Nota sensitive or specific test for the diagnosis of PE. • Atelectasis, Pleural effusion, or a pulmonary parenchymal abnormality is noted most commonly • Only a small portion of patients with PE have a normal CXR.
- 14. The sign resultsfrom a combination of: •dilation of the pulmonary arteries proximal to the embolus •collapse of the distal vasculature creating the appearance of a sharp cut off on chest radiography •The Westermark sign has a low sensitivity (11%) and high specificity (92%) for the diagnosis of pulmonary embolus Radiographic Signs Westermark Sign
- 15. Radiographic Signs –Hamptons Hump Wedge-shaped infarct sensitivity (21) and specificity (82%) for the diagnosis of pulmonary embolus
- 16. Ventilation-Perfusion Scans Usefulif Normal (negative predictive value of 97%) Also useful if High probability (positive predictive value of 85 to 90%) Unfortunately, only diagnostic in 30 to 50% of patients
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- 18. CT Angiography Studieshave shown sensitivity of close to 95% with an experienced observer One of the most commonly cited benefits of CTA is its ability to detect alternative pulmonary abnormalities that may explain the patient's symptoms and signs In 67% of patients without PE, CT provided additional information for alternate diagnosis May predispose patients to further unnecessary testing
- 19. CTAgiogram Acute pulmonary embolismand deep venous thrombosis (DVT) in a 48- year-old woman. Multifocal low-attenuation emboli (arrows) in segmental and subsegmental arteries in the right lower lobe.
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- 21. Pulmonary Angiography inPE The “gold standard” A negative pulmonary angiogram excludes clinically relevant PE. The risk of embolization in patients with a negative angiogram is extremely low
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- 23. Is it importantto use clinical decision rules? • In the setting of no thromboembolic risk factors, it is extraordinarily unlikely (0.95% chance) to have a CT angiogram positive for PE. • With the combination of a negative D- dimer test result, this risk is even lower.
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- 25. When PE issuspected, the modified Wells criteria should be applied to determine if PE is unlikely (score ≤4) or likely (score >4). The modified Wells Criteria include the following: Patients classified as PE unlikely should undergo D-dimer testing with a quantitative rapid ELISA assay or a semiquantitative latex agglutination assay. The diagnosis of PE can be excluded if the D-dimer level is <500 ng/mL or negative.
- 26. Patients classified asPE likely and patients classified as PE unlikely who have a D-dimer level >500 ng/mL should undergo CT-PA. A positive CT-PA confirms the diagnosis of PE. Alternatively, a negative CT-PA excludes the diagnosis of PE. In those rare instances in which the CT-PA is inconclusive, either pulmonary angiography or the diagnostic approach intended for institutions without experience in CT-PA can be used.
- 27. Lower Extremity USindicated? Depends on pre-test probability High pretest probablity for PE and negative CT may require additional testing Good initial test to evaluate for pulmonary embolism in patients with contrast allergy, renal insufficiency, pregnancy, or critically ill patients. Inexpensive test without radiation exposure Can avoid additional testing if positive
- 28. Summary and Recommendations Consideryour patient’s risk factors for pulmonary embolism The clinical presentation of acute pulmonary embolism is variable and nonspecific The major diagnostic tests employed in the evaluation of a patient with suspected PE include d-dimer testing, CTPA, V/Q scanning, venous ultrasonography, and conventional pulmonary angiography Follow a diagnostic algorithm that combines CTPA, d- dimer and clinical assessment
- 29. https://www.facebook.com/groups/1451610115129555/#!/groups/145 1610115129555/ Wellcome in ournew group ..... Dr.SAMIR EL ANSARY
- 30. GOOD LUCK SAMIR ELANSARY ICU PROFESSOR AIN SHAMS CAIRO [email protected]