Pulmonary Embolism
Pulmonary Embolism
Pulmonary embolism Usually arise from a venous thrombosis in the
pelvic or legs. (DVT comprised of 79% of PE cases)
Rare causes include : right ventricular thrombus (post MI)septic
emboli (right sided IE)fat, air or amniotic embolismneoplastic
cellsCommon symptoms : Dyspnea (73%) Pleuritic chest pain
(66%)Cough (37%)Hemoptysis (13 %)
Signs : pyrexia, cyanosis, tachypnea, tachycardia, hypotension,
raised JVP, pleural rub, pleural effusion.
The diagnosis of acute pulmonary embolism often requires a high
index of suspicion, especially since it is an uncommon cause of
chest pain in the primary care setting.
Virchows triad
5Investigations Chest X ray : wedge shape shadow, elevated
diaphragm, pleural effusion and diminished vasculature.
ECG Sinus tachycardia, anterior T wave inversion (V1 to V4),
RAD, RBBB, ST depression in right sided leads, S1Q3T3 may be
present but rare. 6
Hampton Hump
Westermark sign
ABG : hypoxaemia, hypocarbia seen.
Pulmonary angiography : the gold standard for localisation of
primary site of clot.
D dimer : high negative predictive value.
Color doppler ultrasound of the leg veins if suspect DVT.
11Echocardiography : acute dilatation of the right ventricle in
massive pulmonary embolism. 12
Management Treatment is s/c heparin.
Oxygen is given to maintain SpO2 above 90%.
Opiates can be given to relieve pain but used in caution in
hypotensive patients.
External cardiac massage may break up embolus.
14Pulmonary angiography followed by pulmonary embolectomy is the
definitive treatment.
Consider placement of a vena caval filter in patient who develop
emboli despite adequate anticoagulation.
IVC filter
Prevention Give heparin to all immobile patients.
Prescribe compression stockings and encourage early
mobilization.
Stop HRT
If past of family history of thromboembolism, consider
investigation for thrombophilia. Aortic dissection
Aortic dissection A breach in the intergrity of the aortic wall
allows arterial blood to enter the media, which then splits into
two layers, creating a false lumen.
2 primary classifications (1) DeBakey system : Type I, II and
III (2) Stanford system : Type A and Type B
20
Clinical features Sudden, severe, tearing chest pain/ abdominal
pain radiating to the back.
Chest pain associated with neurological symptoms (syncope, TIA,
stroke or paraplegia)
Asymmetry of brachial, carotid or femoral pulses (Pulse deficits
or difference) or BP in lower limbs lower than upper limbs.
Signs of Aortic regurgitation (new onset) and inferior MI can
develop if dissection moves proximally.
23May present with : MI (coronary artery)Stroke (carotid
artery)Paraplegia (anterior spinal artery)Mesenteric infarction
with an acute abdomen (coeliac and superior mesenteric artery)Renal
failure (renal artery)Acute limb ischemia (femoral artery)
Neurological symptoms may occur because of occlusion of
supplying vessels or general hypotension24
Investigation Chest X ray widened upper mediastinumDistortion of
aortic knuckle (Absent in 10%)Extension of aortic shadow >5mm
beyond its calcified wall (Eggshell or calcium sign) Aortic
enlargementLoss of space between aorta and pulmonary arteryNew
pleural effusion (free haemothorax)
26ECG left ventricular hypertrophy in patient with
hypertension.
Doppler echography aortic regurgitation, dilated aortic
root.
Wide aortic knob 30
Treatment Goal of treatment is to prevent death and irreversible
end-organ damage.
Monitor vital signs
Cross match 10u blood.
Give high-flow supplemental oxygen
Give pain relief with IV morphine.
Aim to reduce systolic BP to 100-120mmHg. (1) IV nitroprusside
infusion plus IV propranolol (2) IV labetolol infusion. Indications
for surgical repair of aortic dissection All Stanford type A
dissection
Type B dissection with complications (rupture, severe distal
ischemia, intractable pain, uncontrolled hypertension).
Uncontrolled hypertension
Progression of dissection Thank you
