PULMONARY EMBOLISM THE GREAT MASQUERADER Dr Prakash Mohanasundaram

PULMONARY EMBOLISM “THE GREAT MASQUERADER” Dr. Prakash Mohanasundaram EMERGENCY PHYSICIAN A&E(VINAYAKA)

DEFINITION A&E(VINAYAKA)

Triad: ØHypercoagulability ØStasis to flow ØVessel injury A&E(VINAYAKA)

RISK FACTORS HYPERCOAGULABILITY Ø Ø Ø Malignancy Pregnancy Postpartum status(<4 wks) Estrogen Antiphospholipid antibodies Genetic mutations Factor V Leiden mutation Prothrombin gene mutation Factor VIII mutations Protein C deficiency Protein S deficiency VENOUS STASIS Ø Ø Bed rest >48 hrs Cast or external fixator Recent hospitalisation Long distance automobile or air travel VESSEL INJURY ØRecent surgery requiring endotracheal intubation ØRecent trauma requiring hospitalisation A&E(VINAYAKA)

PATHOPHYSIOLOGY Embolization Physiology Right ventricular dysfunction A&E(VINAYAKA)

EMBOLIZATION Proximal leg DVT Calf vein thrombi Upper extremity thrombosis A&E(VINAYAKA)

PHYSIOLOGY Increased pulmonary vascular resistance Impaired gas exchange Alveolar hyperventilation Increased airway resistance Decreased pulmonary compliance A&E(VINAYAKA)

DEATH “RIGHT VENTRICULAR DYSFUNCTION” A&E(VINAYAKA)

Clinical Features Symptoms in Patients with Angio Proven PTE Symptom Dyspnea Chest Pain, pleuritic Anxiety Cough Hemoptysis Sweating Chest Pain, nonpleuritic Syncope Percent 84 74 59 53 30 27 14 13 A&E(VINAYAKA)

Clinical Features Signs with Angiographically Proven PE Sign Tachypnea > 20/min Rales Accentuated S 2 Tachycardia >100/min Fever > 37. 8 Diaphoresis S 3 or S 4 gallop Thrombophebitis Lower extremity edema Percent 92 58 53 44 43 36 34 32 24 A&E(VINAYAKA)

Unexplained tachypnoea, tachycardia, Hypoxia –Suspect PTE A&E(VINAYAKA)

PRETEST PROBABILITY A&E(VINAYAKA)

DIAGNOSING MODALITIES NON IMAGING NON INVASIVE Ø D-Dimer ELISA Ø ABG Ø ECG INVASIVE ØPulmonary angiography (GOLD STANDARD) ØContrast phlebography Ø Ø Ø CXR Venous ultrasonography Chest CT Lung scanning MR Contrast enhanced Echocardiography A&E(VINAYAKA)

D-dimer Test Fibrin split product Circulating half-life of 4 -6 hours Positive assay > 500 ng/ml Quantitative test have 80 -85% sensitivity, and 93 -100% negative predictive value False Positives: Pregnant Patients Malignancy Advanced age > 80 years Hemmorrhage AMI Hepatic Impairment Post-partum < 1 week Surgery within 1 week Sepsis CVA Collagen Vascular Diseases A&E(VINAYAKA)

ABG Hypoxemia Hypocarbia “ LACK DIAGNOSTIC UTILITY IN PE ” A&E(VINAYAKA)

ECG Ø Most Common Findings: v Tachycardia or nonspecific ST/T -wave changes Ø Acute cor pulmonale or right strain patterns v Tall peaked T-waves in lead II (P pulmonale) v Right axis deviation v RBBB v S 1 -Q 3 -T 3 (occurs in only 20% of PE patients) Ø Atrial fibrillation / Atrial flutter A&E(VINAYAKA)

Chest X ray Westermark’s sign focal oligemia / cut off sign Hampton’s hump peripheral wedge shaped density above the diaphragm Palla’s sign enlarged right descending pulmonary artery ALMOST ALWAYS NORMAL CHEST X RAY A&E(VINAYAKA)

WESTERMARK SIGN A&E(VINAYAKA)

HAMPTON’S HUMP A&E(VINAYAKA)

PALLA’S SIGN A&E(VINAYAKA)

Venous Ultrasonography Loss of vein compressibility ½ of pts with PE have no imaging evidence of DVT A&E(VINAYAKA)

Chest CT Principal imaging test New generation multislice scanners locates thrombi in the fifth order branches Alternative diagnosis Ø Pneumonia Ø Emphysema Ø Pulmonary fibrosis Ø Pulmonary mass Ø Aortic pathology A&E(VINAYAKA)

V/Q SCAN A&E(VINAYAKA)

NORMAL V/Q SCAN A&E(VINAYAKA)

ABNORMAL V/Q SCAN A&E(VINAYAKA)

MR contrast enhanced Results similar compared with first generation CT Also assesses right ventricular function A&E(VINAYAKA)

Echocardiography ½ pts have normal echo DD’s Ø Ø AMI Pericardial tamponade Aortic dissection PE complicated by right heart failure Risk stratification MC CONNEL’s sign – right ventricular free wall hypokinesis with normal right A&E(VINAYAKA) ventricular apical motion

Pulmonary angiography (GOLD STANDARD) Detect emboli as small as 1 to 2 mm RESERVED FOR 1) Technically inadequate CT scans 2) Scans performed on older machines 3) Pts who will undergo interventions A&E(VINAYAKA)

Pulmonary Embolus Arrow indicates abrupt termination of a pulmonary artery. Www. brighamrad. Harvard. edu/cases A&E(VINAYAKA) /bwh/images.

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TREATMENT A&E(VINAYAKA)

DICTUM “ABC” A&E(VINAYAKA)

RISK STRATIFICATION A&E(VINAYAKA)

TREATMENT PRIMARY THERAPY Ø Thrombolysis Ø Embolectomy SECONDARY THERAPY ØAnticoagulation ØIVC filters ADJUNCTIVE THERAPY Ø O 2 Ø Pain relief Ø Dobutamine Ø Caution – volume overload Pulmonary thromboendarterctomy A&E(VINAYAKA)

SCENARIO 45 year male, case of OPC poisoning Being treated with mechanical ventilation Paralysed & sedated for 2 days Develops sudden tachypnoea, tachycardia, hypotension & hypoxia A&E(VINAYAKA)

WHAT IS YOUR LINE OF MANAGEMENT A&E(VINAYAKA)

THROMBOLYSIS Recombinant t. PA 100 mg iv infusion over 2 hours Streptokinase 250, 000 U iv over 30 mins foll by 100, 000 U/hr for 24 hrs Urokinase 4, 4 OO U/kg iv over 10 mins foll by 4, 000 U/kg/hr for 12 hrs Alteplase 15 mg iv bolus foll by 2 hr infusion of 85 mg ( discontinue heparin during infusion) A&E(VINAYAKA)

SCENARIO 45 year male, A case of glioma Underwent craniotomy & evacuation 2 days ago Bed ridden for 2 days Develops sudden tachypnoea, tachycardia, hypotension & hypoxia A&E(VINAYAKA)

WHAT IS YOUR LINE OF MANAGEMENT A&E(VINAYAKA)

EMBOLECTOMY Indicated in pts with risk of thrombolysis Surgical embolectomy Catheter embolectomy A&E(VINAYAKA)

SCENARIO 45 year male, case of OPC poisoning Being treated with mechanical ventilation Paralysed & sedated for 2 days Develops sudden tachypnoea & tachycardia BP - Normal A&E(VINAYAKA)

ECHO NORMAL WHAT IS YOUR LINE OF MANAGEMENT A&E(VINAYAKA)

Heparin / LMWH / Warfarin Heparin 80 U/kg iv bolus foll by 18 U/kg/hr Enoxaparin 1 mg/kg twice daily / 1. 5 mg/kg daily Tinzaparin 175 mg/kg OD Fondaparinux <50 kg receive 5 mg, 50– 100 kg patients receive 7. 5 mg >100 kg receive 10 mg. Warfarin – 2. 5 to 10 mg Target INR – 2. 0 TO 3. 0 A&E(VINAYAKA)

IVC Filters INDICATIONS 1) Active bleeding that precludes anticoagulation 2) Recurrent venous thrombosis despite intensive anticoagulation A&E(VINAYAKA)

PREVENTION OF PULMONARY THROMBOEMBOLISM A&E(VINAYAKA)

SUMMARY > 50 % pts with DVT are associated with PE > 50 % cases do not have any signs or symptoms Common presentation can be unexplained tachycardia, tachypnoea, hypoxemia or mere anxiety Diagnosis and suspicion is purely clinical Follow up with anticoagulants is must as there is a increased risk of recurrence A&E(VINAYAKA)

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