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Good Morning and Welcome Applicants!. November 11, 2010. Acute Pulmonary Embolism. Origin Deep venous system of lower extremities, right heart, pelvic, renal or upper extremity veins Travel to lungs Large thrombi Lodge at bifurcations and can cause hemodynamic compromise Small thrombi - PowerPoint PPT PresentationTRANSCRIPT
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Good Morning and Welcome Applicants!November 11, 2010
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Acute Pulmonary Embolism
•Origin▫Deep venous system of lower extremities,
right heart, pelvic, renal or upper extremity veins
•Travel to lungs▫Large thrombi
Lodge at bifurcations and can cause hemodynamic compromise
▫Small thrombi Travel distally cause pleuritic chest pain
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•Impaired gas exchange▫Mechanical obstruction – V/Q mismatch▫Inflammatory mediators
Surfactant dysfunction, atelectasis and functional intrapulmonary shunting
•Hypotension▫Diminished CO
Increased PVR leading to decreased RV outflow and decreased LV preload
Acute Pulmonary Embolism - Pathophysiology
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Acute Pulmonary Embolism• More than half of all PE
are underdiagnosed• Mortality rate 30%
without treatment▫Reduced to 2-8% with
anticoagulation▫RV dysfunction
associated with two-fold increase
▫RV thrombus ▫BNP▫Serum troponins
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VTE in Children• Central Venous Access
▫ Associated with 2/3 of VTEs in children
• Inherited Hypercoagulable State
• Other Conditions▫ Infection, Congenital Heart Disease, Trauma,
Nephrotic Syndrome, Lupus Erythematosus or complication from chemotherapy (L-asparaginase and steroids) for ALL
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Acute Pulmonary Embolism• Clinical Signs
▫ Pleuritic chest pain▫ Tachypnea▫ Cough▫ Tachycardia▫ Acute dyspnea▫ Signs of DVT▫ Sudden collapse▫ Most common – nonspecific▫ PE should be considered in the differential
diagnosis of cardiorespiratory deterioration in all critically ill children
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• Modified Wells Criteria for PE ▫ Clinical symptoms of DVT (3 points) ▫ Other diagnosis less likely than PE (3 points) ▫ Heart rate >100 (1.5 points) ▫ Immobilization or surgery in previous four weeks (1.5
points) ▫ Previous DVT/PE (1.5 points) ▫ Hemoptysis (1 point) ▫ Malignancy (1 point)
• Traditional clinical probability assessment:▫ High >6▫ Moderate 2 to 6▫ Low <2
• Simplified clinical probability assessment:▫ PE likely (score >4)▫ PE unlikely (score <=4)
Diagnosis of Acute Pulmonary Embolism
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Diagnosis of Acute Pulmonary Embolism
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Vocal Cord Dysfunction•AKA – Paradoxical
vocal cord motion (PVCM)
•Paradoxical vocal cord adduction during inspiration
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Vocal Cord Dysfunction•Signs
▫Wheezing▫Stridor▫Dyspnea▫Cough▫Chest tightness▫Exercise intolerance
•F>M•20-40y
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Vocal Cord Dysfunction•Medical Risk Factors
▫Asthma (50%)▫GER▫CF▫Postnasal drip▫Cold air▫Cigarette smoke▫Brainstem abnormalities▫Stroke▫Myasthenia gravis
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Vocal Cord Dysfunction•Psychological Risk Factors
▫Anxiety over school performance▫Parent-child conflict▫Divorce▫Emotional upset▫Abuse▫Psychiatric disturbances
Somatization disorder
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VCD vs AsthmaVCD Asthma• Inspiratory dyspnea• Abnormalities heard on
inspiration• No response to
bronchodilators• Normal ABG if hypoxemic
▫ Normal A-A gradient• Normal CXR• PFTs
▫ Flattening of inspiratory limb
• Expiratory dyspnea• Abnormalities heard on
expiration• Respond to
bronchodilators
• Abnormal ABG if hypoxemic▫ VQ mismatch
• CXR with hyperinflation• PFTs
▫ Scooped out expiratory limb
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VCD Diagnosis•Direct
visualization
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VCD Management•Mulitdisciplinary•Primary cause if present•Acute
▫Panting ▫Short acting benzos
•Long-term▫Speech therapy▫Relaxation techniques▫Psychological intervention▫Education