Uploaded bycamiij1
Pulmonary thromboembolism
Pulmonary embolism (PE) is a blockage in the lungs caused by blood clots that travel from deep veins, usually in the legs. It is the third most common cause of death in hospitalized patients, with over 650,000 cases occurring per year in the US. Risk factors include immobilization, hypercoagulability, and recent surgery or trauma. Symptoms can include chest pain, shortness of breath, cough, or fainting. Diagnosis is confirmed through imaging tests like CT angiography or ventilation-perfusion scans. Treatment involves blood thinners like heparin, warfarin, or newer oral anticoagulants to prevent further clotting. Thrombolytic drugs
More Related Content
![Interstitial Lung Diseases [ILD] Approach to Management](https://cdn.slidesharecdn.com/ss_thumbnails/interstitiallungdiseases-arunvasireddy-19october2015-seminar-171016041856-thumbnail.jpg?width=640&height=640&fit=bounds)
Similar to Pulmonary thromboembolism
Pulmonary thromboembolism
- 1. PULMONARY THROMBOEMBOLISM Camille Renee Dr. E.B. PDCM14091 STV vista.engines4ed.or
- 2. EPIDEMIOLOGY • Pulmonary embolismis present in 60-80% of patients with DVT, but most patients are asymptomatic. Pulmonary embolism is the third most common cause of death in hospitalized patients, with 650,000+ cases occurring per year • The incidence of pulmonary embolism appears to be significantly higher in blacks than in whites. • Pulmonary embolism is increasingly prevalent among elderly patients, yet the diagnosis is missed more often in these patients than in younger ones because • DVT and pulmonary embolism are rare in pediatric practice Medscape,
- 3. EPIDEMIOLOGY • Pulmonary embolismaccounts for approximately 15% of all postoperative deaths • The incidence of pulmonary embolism in the United States is estimated to be 1 case per 1000 persons per year • Death rate has decreased more than 50% between 1979-1998 Medscap
- 4. WHAT IS APULMONARY EMBOLISM (PE)? • Pulmonary emboli usually arise from thrombi that originated in the deep venous system of the lower extremities (most commonly the calf veins) • To reach the lungs, thromboemboli travel through the right side of the heart • Representative of underlying venous thrombosis • May present as sudden death Youtube, First Aid 2014,
- 5. TYPES OF EMBOLI •Fat, Air, Thrombus, Bacteria, Amniotic fluid, Tumor (FAT BAT) • Fat emboli: associated with long bone fractures and liposuction; Classic triad of symptoms: hypoxemia, neurologic abnormalities, and petechiae • Amniotic fluid emboli: postpartum can lead to DIC • Gas emboli: N2 bubble accumulation in First Aid 2014
- 6. CLINICAL MANIFESTATIONS: SYMPTOMS •Sudden-onset pleuritic chest pain and shortness of breath. However, most patients with PE rarely display this classic presentation. • The PIOPED (Prospective Investigation of Pulmonary Embolism Diagnosis) Study reported 4 common symptoms: dyspnea, pleuritic chest pain, cough, and hemoptysis • Atypical symptoms include: Seizures, Syncope, Abdominal pain, Fever, Productive cough, Wheezing, Decreasing level of consciousness, New onset of atrial fibrillation, Hemoptysis, Flank pain, Delirium (in elderly patients) Medscape, First Aid 2014,
- 7. PATIENT HISTORY • Apatient with a pulmonary embolism tends to have a history that may include: Immobilization, hypercoagulability, venous stasis, pregnancy, IBD, pacemakers, varicose veins, venography, hemolytic anemia, thrombocytopenia, oral contraceptives, hormonal replacements • The PIOPED Study classified the following risks for PE: Recent travel or surgery and/or a history of stroke, smoking, prior PE, heart failure, trauma, COPD, or thrombophlebitis Medscape,
- 8. CLINICAL MANIFESTATIONS: SIGNS •Tachypnea (respiratory rate >16/min): 96% • Rales (clicking, rattling, or crackling noises during inhalation): 58% • Accentuated second heart sound: 53% • Tachycardia (heart rate >100/min): 44% • Fever (temperature >37.8°C): 43% • Other manifestations may include: Diaphoresis: 36%; S 3 or S 4 gallop: 34%; Clinical signs and symptoms suggesting thrombophlebitis: 32%; Lower extremity edema: 24%; Cardiac murmur: 23%; Cyanosis: 19% Medscape
- 9. PHYSICAL EXAMINATION • Massivepulmonary embolism: IN HYPOXIC SHOCK, physical signs of pulmonary hypertension • Acute pulmonary infarction: palpable/audible pleural friction rub, localized tenderness • Acute embolism without infarction: pleuritic chest pain, crackles, local wheezing • Multiple pulmonary emboli or thrombi: JVD • Children: pleural rub, physical findings are less remarkable Medscape
- 10. SIGNS OF PULMONARYHYPERTENSION • Palpable impulse over 2nd left intercostal space, loud P2, S3 gallop, systolic murmur louder on inspiration at left sternal border Medscape, Bibby
- 11. DIFFERENTIAL DIAGNOSES 1. Pericarditis 2.Cor Pulmonale 3. Dilated Cardiomyopathy Medscape,
- 12. • Thrombus formation •Virchow’striad: 1.Endothelial injury 2.Stasis or turbulence of blood flow 3.Blood hypercoagulability • Venous stasis, Hypercoagulable states, Immobilization, Surgery and trauma, Pregnancy, Oral contraceptives and estrogen replacement, Malignancy, Hereditary factors, Acute medical illness WHAT CAUSES A PE TO OCCUR? Medscape,
- 13. CONFIRMATORY TESTS LABORATORY TESTS •D-dimer/FSP testing • Ischemia-modified albumin level • WBC count • Arterial blood gas: respiratory alkalosis with low pCO2, hypoxemia • Others: Serum troponin level, Brain natriuretic peptide IMAGING TESTS • Multidetector-row CTA (MDCTA): criterion gold standard for diagnosing pulmonary embolism • CXR: tends to be normal! • V/Q scan: mismatch • Also: MRI, TEE, ECG (tachycardia and nonspecific Medscape, First Aid 2014,
- 14. V/Q MISMATCH • Theperfusion scan shows perfusion defects whereas the ventilation scan was normal; this is termed a mismatch, signifying that this is a high-probability scan Medscape
- 15. HAMPTON HUMP SIGNMAY BE PRESENT • Left: CXR shows a wedge-shaped infiltrate on the periphery caused by pulmonary infarction secondary to PE (Hampton hump) • Right: CT image of triangular, pleura-based infarction/consolidation (Hampton hump) Medscap
- 16. WESTERMARK SIGN MAYALSO BE PRESENT • The Westermark sign (aka ‘knuckle sign’) represents oligemia (leading to vessel collapse) seen distal to a PE. Only seen in 2% of patients. NEJM.org,
- 17. HYPERCOAGULABLE DISEASES CANLEAD TO PE 1. Antithrombin III deficiency 2. Protein C or protein S deficiency 3. Lupus anticoagulant 4. Homocystinuria 5. Occult (hidden) neoplasm 6. Connective tissue disorders Medscape,
- 18. TREATMENT OPTIONS: THROMBOLYTICS •Alteplase • Reteplase • Urokinase • Streptokinase Medscape,
- 19. HOW DO THEYWORK? • Serine proteases (digest protein) and essentially convert plasminogen to plasmin to break down fibrinogen and fibrin and dissolve the clot (tPA) • Adverse effect: fatal bleeding Medicinenet,
- 20. TREATMENT OPTIONS: ANTICOAGULANTS •Unfractionated heparin, Low-molecular-weight heparin, Factor Xa Inhibitors i.e. Fondaparinux, Warfarin • The US Food and Drug Administration (FDA) has recently extended the use of the oral anticoagulant apixaban (factor Xa inhibitor) to treat both PE and DVT • Surgical embolectomy can also be performed in severe cases: https://www.youtube.com/watch?v=SzsQWIMYbN8 Medscape,
- 21. HOW DO THEYWORK? • Warfarin reduces the production of the factors because it antagonizes vitamin K, a molecule clotting factors need to function. • Adverse Effect: Bleeding and necrosis (gangrene) Medicinenet,
- 22.
- 23. QUESTION 1 • Themnemonic ‘FAT BAT’ is used to remember the following 6 types of emboli known to cause a pulmonary embolism: a) Fluid, Air, Thrombus, Blood, Amniotic fluid, Tumor b) Fat, Air, Thrombus, Bacteria, Amniotic fluid, Tumor c) Fat, Acid, Trauma, Blood, Antithrombin, Thrombus d) Fibrous lesion, Air, Trauma, Bacteria, Acid, Thrombus
- 24. ANSWER •B The 6types of emboli known to cause PE are Fat, Air, Thrombus, Bacteria, Amniotic fluid, Tumor (FAT BAT). First Aid
- 25. QUESTION 2 • Whichof the following tests is the most specific confirmatory finding for PE? a) Westermark sign on CXR b) Hampton hump sign on CXR c) Thrombus seen on venography d) Embolus seen on MDCTA e) ECG
- 26. ANSWER •D Multidetector-row computedtomography angiography (MDCTA) is the criterion gold standard for diagnosing pulmonary embolism. Medscape
- 27. QUESTION 3 • TheFood and Drug Administration has recently approved the following drug to be used to treat pulmonary embolisms: a) Apixaban b) Streptokinase c) Fondaparinux d) LMWH
- 28. ANSWER •A The USFood and Drug Administration (FDA) has recently extended the use of the oral anticoagulant apixaban (factor Xa inhibitor) to treat both PE and DVT. Medscape
- 29.
- 30. REFERENCES 1. Pulmonary Embolism.2015. Medscape Emedicine. http://emedicine.medscape.com/article/300901- overview#aw2aab6b2b4 2. Le, T., Bhushan, V., & Sochat, M. (2014). First aid for the usmle step 1. McGraw-Hill: Chicago. 3. MedicineNet. http://www.medicinenet.com
- 31.
- 32. 2. A pulmonaryangiogram shows the abrupt termination of the ascending branch of the right upper-lobe artery (Westermark sign), confirming the diagnosis of pulmonary embolism. Medscape
- 33. 3. Emboli mostcommonly arise from the calf veins, though they may arise from other parts of the body. The venous thrombi predominately originate in venous valve pockets (inset). To reach the lungs, thromboemboli travel through the right side of the heart. Medscape
- 34.
Editor's Notes
- #2 http://emedicine.medscape.com/article/300901-overview#aw2aab6b2b4 vista.engines4ed.org
- #5 POSTSURGICAL COMPLICATION!
- #15 http://www.nejm.org/doi/full/10.1056/NEJMicm1107936
- #18 Lupus anticoagulant is a misnomer, as it is actually a prothrombotic agent. The term "anticoagulant" accurately describes its function in vitro. However in vivo, it functions as a pro-coagulant. CT disorders ie vasculites
- #34 The pathophysiology of pulmonary embolism. Although pulmonary embolism can arise from anywhere in the body, most commonly it arises from the calf veins. The venous thrombi predominately originate in venous valve pockets (inset) and at other sites of presumed venous stasis. To reach the lungs, thromboemboli travel through the right side of the heart. RA, right atrium; RV, right ventricle; LA, left atrium; LV, left ventricle.