Post-Op Pulmonary EmbolismPost-Op Pulmonary Embolism

Linda P. Zhang, MS IIILinda P. Zhang, MS IIIScott Q. Nguyen, M.D.Scott Q. Nguyen, M.D.Celia M. Divino, M.D.Celia M. Divino, M.D.

Mount Sinai School of MedicineMount Sinai School of Medicine

Mrs. MargoMrs. Margo

Your patient in the hospital is a 62 year- old Your patient in the hospital is a 62 year- old female with a 1 hour history of shortness of female with a 1 hour history of shortness of breath, s/p a right total hip replacement 4 days breath, s/p a right total hip replacement 4 days ago. ago.

HistoryHistory

What other points of the history do What other points of the history do you want to know?you want to know?

History, Mrs. MargoHistory, Mrs. Margo Consider the following:Consider the following:

Characterization of Symptoms: Characterization of Symptoms: New sudden onset SOB and New sudden onset SOB and tachypnea while lying in bed. Pain tachypnea while lying in bed. Pain with breathing. Intermittent cough with breathing. Intermittent cough with no hemoptysis. Feeling of with no hemoptysis. Feeling of apprehension.apprehension.

Temporal sequence Temporal sequence Total hip replacement 4 days prior, Total hip replacement 4 days prior, no complications since surgery. no complications since surgery. Has not been ambulating since Has not been ambulating since surgery. surgery.

Alleviating/Exacerbating factors:Alleviating/Exacerbating factors:Aggravated by breathingAggravated by breathing

Pertinent PMHPertinent PMHL breast cancer, s/p modified radical L breast cancer, s/p modified radical mastectomy and radiation 2 yr ago.mastectomy and radiation 2 yr ago.

ROS:ROS: no palpitations, no peripheral no palpitations, no peripheral edema.edema.

MEDS:MEDS: PercocetPercocet

Differential Diagnosis ?Differential Diagnosis ?

Differential DiagnosisDifferential DiagnosisBased on History and PresentationBased on History and Presentation

Pulmonary embolismPulmonary embolism Aspiration pneumonitisAspiration pneumonitis Myocardial infarctionMyocardial infarction Heart failure / Pulmonary EdemaHeart failure / Pulmonary Edema PneumothoraxPneumothorax ARDSARDS

Physical ExaminationPhysical Examination

What would you look for?What would you look for?

Physical Examination, Mrs. MPhysical Examination, Mrs. M Vital Signs:Vital Signs: T 37.5, pulse 105, BP 135/85, RR 26, T 37.5, pulse 105, BP 135/85, RR 26, O2 Sat:O2 Sat: 89% Room air 89% Room air Appearance:Appearance: AAOx3, anxiousAAOx3, anxious

Chest:Chest: CTABCTAB

CV:CV: RRR, tachycardic, accentuated P2. (+) S4 RRR, tachycardic, accentuated P2. (+) S4

Abd:Abd: normo-active bowel sound, soft, nontender non-distendednormo-active bowel sound, soft, nontender non-distended

Rectal:Rectal: guaiac negativeguaiac negative

Extremities:Extremities: No thigh or calf swelling. No localized tenderness or No thigh or calf swelling. No localized tenderness or erythema along veins. (-) calf pain upon passive dorsiflexion of feet (erythema along veins. (-) calf pain upon passive dorsiflexion of feet (what what sign is this?sign is this?). No clubbing/edema/cyanosis). No clubbing/edema/cyanosis

Remaining Examination findings non-contributory

Would you like to revise your Would you like to revise your Differential Diagnosis?Differential Diagnosis?

Revised Differential Diagnosis Revised Differential Diagnosis

Pulmonary EmbolismPulmonary Embolism Heart Failure / Pulmonary EdemaHeart Failure / Pulmonary Edema MIMI Aspiration pneumonitisAspiration pneumonitis

LaboratoryLaboratory

What would you obtain?What would you obtain?

Labs ordered, Mrs. MargoLabs ordered, Mrs. Margo

CBC: Hb/Hematocrit/WBCCBC: Hb/Hematocrit/WBC

PT/PTT/ PlateletsPT/PTT/ Platelets

ABGABG

Cardiac EnzymesCardiac Enzymes

Lab Results, Mrs. MargoLab Results, Mrs. Margo

CBC: Hb CBC: Hb

HematocritHematocrit

WBCWBC

13.313.3

3737

12.112.1

PT/PTT/Platelet:PT/PTT/Platelet: 11/24/37511/24/375

ABG:ABG: 7.48/27/55 O7.48/27/55 O22 sat 89% sat 89%

Cardiac enzyme:Cardiac enzyme: Troponin 1.2Troponin 1.2

Lab Results, DiscussionLab Results, Discussion

CBC:CBC: can be done to r/o elevated WBC secondary to can be done to r/o elevated WBC secondary to pulmonary infection, and to r/o decreasing H/H secondary to pulmonary infection, and to r/o decreasing H/H secondary to occult bleeding. occult bleeding.

ABGs:ABGs: can be done to determine acid-base imbalance and to can be done to determine acid-base imbalance and to r/o pulmonary or renal disease. r/o pulmonary or renal disease.

• Hypoxemia, hypocapnia, respiratory alkalosis secondary to Hypoxemia, hypocapnia, respiratory alkalosis secondary to tachypnea, and tachypnea, and ↑ ↑ A-a gradient may suggest PE.A-a gradient may suggest PE.

• However, massive PE with respiratory collapse can present as However, massive PE with respiratory collapse can present as hypercapnia and combined respiratory and metabolic acidosis.hypercapnia and combined respiratory and metabolic acidosis.

Troponin I and TTroponin I and T: : can do done to r/o MI. May be elevated can do done to r/o MI. May be elevated in moderate to large PE secondary to acute right heart in moderate to large PE secondary to acute right heart overload. overload.

Interventions at this point?Interventions at this point?

Interventions at this point?Interventions at this point?

Supplemental Oxygen Supplemental Oxygen

StudiesStudies

What further studies would you want at this What further studies would you want at this time?time?

Studies, Mrs. MargoStudies, Mrs. Margo

EKGEKG Chest x-rayChest x-ray

EKG, DiscussionEKG, Discussion

EKG:EKG:• Can be used to r/o arrhythmias, ischemia, MI, Can be used to r/o arrhythmias, ischemia, MI,

and axis-deviation.and axis-deviation.• For PE: see tachycardia, R axis deviation and For PE: see tachycardia, R axis deviation and

nonspecific ST and T wave changes.nonspecific ST and T wave changes. − Classic findings of S wave in Lead I, Q wave in Lead III, Classic findings of S wave in Lead I, Q wave in Lead III,

and T wave inversion in Lead III seen in <20% of cases.and T wave inversion in Lead III seen in <20% of cases.− May also see RBBB, P pulmonale, atrial fib.May also see RBBB, P pulmonale, atrial fib.

Chest x-ray, DiscussionChest x-ray, Discussion

Chest x-ray, DiscussionChest x-ray, Discussion

Chest x-ray:Chest x-ray: Can be used to r/o pneumothorax, ARDS, pneumonia.Can be used to r/o pneumothorax, ARDS, pneumonia. For PE, abnormal chest x-ray findings are common but For PE, abnormal chest x-ray findings are common but

nonspecific: atelectasis, pleural effusion, infiltrates. May seenonspecific: atelectasis, pleural effusion, infiltrates. May see Hampton’s hump Hampton’s hump oror Westermark’s sign. Westermark’s sign. In most cases, the In most cases, the CXR will be clear.CXR will be clear.

Cardiomegaly is a common radiographic finding in PECardiomegaly is a common radiographic finding in PE

Intervention at this point?Intervention at this point?

Intervention at this point?Intervention at this point?

Start therapeutic-dose heparin:Start therapeutic-dose heparin:• Given the strong clinical suspicion for PE, it may be Given the strong clinical suspicion for PE, it may be

necessary to start heparin prior to initiating any necessary to start heparin prior to initiating any diagnostic studies. diagnostic studies.

• Must watch out for post-surgical bleeding when Must watch out for post-surgical bleeding when patient is placed on heparin. patient is placed on heparin.

What next?What next?

To diagnose PE (initial study):To diagnose PE (initial study):

V/Q scan, DiscussionV/Q scan, Discussion

V/Q scan:V/Q scan:

The most frequently used test in diagnosing PE.The most frequently used test in diagnosing PE. Advantages: NoninvasiveAdvantages: Noninvasive Disadvantages: Disadvantages:

− diagnostic value is dependent on the result:diagnostic value is dependent on the result:•A normal V/Q scanA normal V/Q scan = 5% chance of patient having PE = 5% chance of patient having PE•A high probability V/Q scanA high probability V/Q scan = 85% chance of patient having PE = 85% chance of patient having PE•An intermediate or low probability V/Q scanAn intermediate or low probability V/Q scan = non-diagnostic, a = non-diagnostic, a pulmonary angiogram is needed for definitive diagnosis.pulmonary angiogram is needed for definitive diagnosis.

− In over 50% of cases, the V/Q scan result will be either intermediate or low In over 50% of cases, the V/Q scan result will be either intermediate or low probability, thus rendering the result non-diagnostic.probability, thus rendering the result non-diagnostic.

− Not always readily available as a diagnostic test. Not always readily available as a diagnostic test.

Initial diagnostic tool for PE:Initial diagnostic tool for PE:

VQ pictureVQ picture

Low Probability Ventilation Perfusion Scan

Studies – Results for Mrs. MargoStudies – Results for Mrs. Margo

V/Q scan result:V/Q scan result:• Intermediate probability scanIntermediate probability scan

What is the differential diagnosis at this What is the differential diagnosis at this point?point?

Revised Differential DiagnosisRevised Differential Diagnosis

Pulmonary EmbolismPulmonary Embolism Possible early MIPossible early MI

What next?What next?

What Next?What Next?

CT angiographyCT angiography

CT angiography, DiscussionCT angiography, Discussion CT angiographyCT angiography

Frequently used as follow-up test after a non-diagnostic V/Q scan. Frequently used as follow-up test after a non-diagnostic V/Q scan. Advantages:Advantages:

• Noninvasive, but requires contrast. Do not give for patients with Noninvasive, but requires contrast. Do not give for patients with renal insufficiency/failure.renal insufficiency/failure.

• Readily available test. Readily available test. • Sensitivity and specificity greater than 90%.Sensitivity and specificity greater than 90%.

Disadvantages:Disadvantages:• Can detect emboli in proximal pulmonary arteries and segmental Can detect emboli in proximal pulmonary arteries and segmental

arteries, but very limited in detection of emboli beyond segmental arteries, but very limited in detection of emboli beyond segmental arteries. arteries.

• Immediate post-op PE are fresh clots that are easily fragmented, and Immediate post-op PE are fresh clots that are easily fragmented, and thus more likely to be found in the periphery. As such, CT angio thus more likely to be found in the periphery. As such, CT angio would not be a good diagnostic tool for immediate post-op PE. would not be a good diagnostic tool for immediate post-op PE.

• Technician- and reader-dependent. Positive and negative results must Technician- and reader-dependent. Positive and negative results must be interpreted with caution.be interpreted with caution.

• Difficult to see obliquely/horizontally oriented vessels within the Difficult to see obliquely/horizontally oriented vessels within the right middle lobe and left lingula.right middle lobe and left lingula.

CT angiography of PECT angiography of PE

Large clot in Right Large clot in Right

pulmonary artery (arrow).pulmonary artery (arrow).

Other studies, DiscussionOther studies, Discussion

There are multiple other diagnostic tools that can be used to There are multiple other diagnostic tools that can be used to help diagnose PE:help diagnose PE:

Pulmonary AngiographyPulmonary Angiography• Considered the historical gold standard for diagnosing PEConsidered the historical gold standard for diagnosing PE• On image, see a filling defect or sharp cutoff of small vessels. On image, see a filling defect or sharp cutoff of small vessels. • Advantages:Advantages:

Best diagnostic yield. If negative result, PE can be excluded from differential. Best diagnostic yield. If negative result, PE can be excluded from differential. • Disadvantages:Disadvantages:

Invasive, and requires contrast. Invasive, and requires contrast. Patients who have long-standing pulmonary arterial hypertension and right Patients who have long-standing pulmonary arterial hypertension and right

ventricular failure should not undergo a pulmonary angiography.ventricular failure should not undergo a pulmonary angiography.• Pulmonary angiography should be the initial test for critically ill patients. Pulmonary angiography should be the initial test for critically ill patients.

It should be obtained immediately after clinical episode. Otherwise, it may It should be obtained immediately after clinical episode. Otherwise, it may result in a false negative. result in a false negative.

Other studies, DiscussionOther studies, Discussion Venography/duplex ultrasoundVenography/duplex ultrasound

• For stable patients with suspect PE and adequate cardiopulmonary reserve (absence For stable patients with suspect PE and adequate cardiopulmonary reserve (absence of hypotension or severe hypoxemia), a duplex ultrasound can be done to rule in of hypotension or severe hypoxemia), a duplex ultrasound can be done to rule in DVT if the V/Q scan was inconclusive. DVT if the V/Q scan was inconclusive.

• Advantages:Advantages:‾ Noninvasive. Easily available. FastNoninvasive. Easily available. Fast

• Disadvantage:Disadvantage:‾ High sensitivity (89-100%) and specificity (89-100%) for detection of High sensitivity (89-100%) and specificity (89-100%) for detection of

proximal DVT in symptomatic patients. However, in patients without proximal DVT in symptomatic patients. However, in patients without symptoms of DVT, sensitivity is only 38% and positive predictive value is symptoms of DVT, sensitivity is only 38% and positive predictive value is 26%. 26%.

‾ If suspect PE but duplex scan is negative, must perform follow-up imaging. If If suspect PE but duplex scan is negative, must perform follow-up imaging. If positive scan for DVT, start anticoagulation positive scan for DVT, start anticoagulation

D-dimer:D-dimer:• Rarely helpful in diagnosing PE in patients with recent surgeryRarely helpful in diagnosing PE in patients with recent surgery• In non-post-op situations where D-dimer is done, PE can be excluded from the In non-post-op situations where D-dimer is done, PE can be excluded from the

differential if D-dimer result is negative (negative predictive value of 95%). If the differential if D-dimer result is negative (negative predictive value of 95%). If the result is positive, further workup needs to be done. result is positive, further workup needs to be done.

Doppler Venous US

Normal Common Femoral Vein by Doppler US

ManagementManagement

Initial Management, Mrs. MargoInitial Management, Mrs. Margo

After initial intervention of heparin and After initial intervention of heparin and supplemental oxygen:supplemental oxygen:• RR decreased to 18 breaths per minuteRR decreased to 18 breaths per minute• O2 sat increased to 93%O2 sat increased to 93%

What should be done next?What should be done next?

Management, Mrs. MargoManagement, Mrs. Margo

Unfractionated heparin – Unfractionated heparin – • Continue for next 7 daysContinue for next 7 days

• Maintain PTT level between 46-70 secMaintain PTT level between 46-70 sec

Warfarin – Warfarin – • Give warfarin simultaneously with heparinGive warfarin simultaneously with heparin

• Maintain INR between 2.0-3.0Maintain INR between 2.0-3.0

Long term management: Long term management: continue warfarin for 6 continue warfarin for 6 months. months.

PE Management, DiscussionPE Management, Discussion

PE management focuses on preventing further blood clot PE management focuses on preventing further blood clot formation, lysis of current clot, and prevention of formation, lysis of current clot, and prevention of recurrent PE. recurrent PE.

Initial intervention: unfractionated heparin or low Initial intervention: unfractionated heparin or low molecular weight heparin:molecular weight heparin:• Unfractionated heparin: IV, PTT should be 46-70 secs (1.5-2.3 x’s the Unfractionated heparin: IV, PTT should be 46-70 secs (1.5-2.3 x’s the

control)control)• LMWH: SQ, greater bioavailability, fixed dose, QD or BID, no need to LMWH: SQ, greater bioavailability, fixed dose, QD or BID, no need to

monitor PTTmonitor PTT• LMWH is equally effective as unfractionated heparin in treatment of LMWH is equally effective as unfractionated heparin in treatment of

PE.PE.• Complications: retroperitoneal bleeding, intracranial bleeding, heparin-Complications: retroperitoneal bleeding, intracranial bleeding, heparin-

induced thrombocytopenia (HIT)induced thrombocytopenia (HIT)

PE Management, DiscussionPE Management, Discussion

Addition of oral anticoagulant: WarfarinAddition of oral anticoagulant: Warfarin• Initiate at the same time as heparin, or after diagnosis of PE.Initiate at the same time as heparin, or after diagnosis of PE.

• Overlap with heparin for at least 5 days and continue until Overlap with heparin for at least 5 days and continue until INR is within therapeutic range for 2 consecutive days before INR is within therapeutic range for 2 consecutive days before discontinuing heparin. discontinuing heparin.

• Maintain INR between 2.0-3.0. Must check INR 2x/wk for 1Maintain INR between 2.0-3.0. Must check INR 2x/wk for 1stst few weeks, once weekly for next several months, and once few weeks, once weekly for next several months, and once monthly thereafter if patient is stable.monthly thereafter if patient is stable.

PE Management, DiscussionPE Management, Discussion

Long term prophylaxis: WarfarinLong term prophylaxis: Warfarin• For 1For 1stst PE event with reversible or time-limited risk PE event with reversible or time-limited risk

factor (i.e. surgery, immobilization, trauma), factor (i.e. surgery, immobilization, trauma), continue warfarin for 3-6 months. continue warfarin for 3-6 months.

• For idiopathic 1For idiopathic 1stst thromboembolic event, continue thromboembolic event, continue warfarin for at least 6 mos. warfarin for at least 6 mos.

• For 2For 2ndnd PE event, cancer, non-modifiable risk PE event, cancer, non-modifiable risk factors, continue warfarin for at least 12 mos or factors, continue warfarin for at least 12 mos or indefinitely.indefinitely.

Hospital Course, Mrs. MargoHospital Course, Mrs. Margo

Pt remains clinically stable, with only mild Pt remains clinically stable, with only mild hypoxemia for the remainder of that day. No hypoxemia for the remainder of that day. No signs of right ventricular failure. signs of right ventricular failure.

Pt recovers uneventfully, and is discharged Pt recovers uneventfully, and is discharged home on Day 10 with warfarin for 6 months. home on Day 10 with warfarin for 6 months.

DiscussionDiscussionEpidemiology:Epidemiology: Pulmonary embolism occurs in over 500,000 patients in the US annually, resulting Pulmonary embolism occurs in over 500,000 patients in the US annually, resulting

in approximately 200,000 deaths. Without prophylaxis, 4-7% of patients with hip in approximately 200,000 deaths. Without prophylaxis, 4-7% of patients with hip surgery will die of PE. Untreated PE results in approximately 30% mortality rate. surgery will die of PE. Untreated PE results in approximately 30% mortality rate.

Patients presenting with PE who survive the initial insult usually die from recurrent Patients presenting with PE who survive the initial insult usually die from recurrent PE during the initial treatment period. PE during the initial treatment period.

Pathophysiology:Pathophysiology: Significant PE are generally from thrombosis formation from deep veins of the Significant PE are generally from thrombosis formation from deep veins of the

thigh and pelvis. Large thrombi, after dislodging from DVT, travel to the lung and thigh and pelvis. Large thrombi, after dislodging from DVT, travel to the lung and become lodged at the main pulmonary artery or lobar branches, causing become lodged at the main pulmonary artery or lobar branches, causing hemodynamic compromise. Small thrombi travel to distal areas of lung, producing hemodynamic compromise. Small thrombi travel to distal areas of lung, producing pleuritic pain secondary to inflammatory response by parietal pleura. pleuritic pain secondary to inflammatory response by parietal pleura.

Only 10% of PE cause pulmonary infarction. Only 10% of PE cause pulmonary infarction. Most PE are multiple and are more likely to travel to lower lobesMost PE are multiple and are more likely to travel to lower lobes Risk factors: immobilization, surgery within last 3 months, malignancy, stroke, and Risk factors: immobilization, surgery within last 3 months, malignancy, stroke, and

history of venous thromboembolism, Factor V Leiden mutation, Protein C and history of venous thromboembolism, Factor V Leiden mutation, Protein C and Protein S deficiency, or Antithrombin III deficiency. Protein S deficiency, or Antithrombin III deficiency.

DiscussionDiscussion

Minor PEMinor PE Patients with minor PE can present with transient dyspnea and cardiac Patients with minor PE can present with transient dyspnea and cardiac

irritability, which may resolve in a few moments. The onset of symptoms irritability, which may resolve in a few moments. The onset of symptoms can be immediately post surgery to 7 days post-op. If patient is considered can be immediately post surgery to 7 days post-op. If patient is considered to be at substantial risk and anticoagulation is not contraindicated, heparin to be at substantial risk and anticoagulation is not contraindicated, heparin therapy can be given while diagnostic tests are being ordered. If therapy can be given while diagnostic tests are being ordered. If anticoagulation may be risky and/or PE seems unlikely, a D-dimer can be anticoagulation may be risky and/or PE seems unlikely, a D-dimer can be performed (in cases of non-post-operative patients). A negative result performed (in cases of non-post-operative patients). A negative result excludes PE from the differential. If the result is positive, a pulmonary excludes PE from the differential. If the result is positive, a pulmonary angiography must be done to confirm the diagnosis of PE. In the angiography must be done to confirm the diagnosis of PE. In the meantime, heparin therapy should be continued. meantime, heparin therapy should be continued.

If PE occurred within 10 days after surgery, a D-dimer test can give a false If PE occurred within 10 days after surgery, a D-dimer test can give a false positive result. As such, a pulmonary angiography should be obtained. positive result. As such, a pulmonary angiography should be obtained.

For critically ill patients who do not tolerate diagnostic tests well, For critically ill patients who do not tolerate diagnostic tests well, pulmonary angiography should be the initial study.pulmonary angiography should be the initial study.

DiscussionDiscussion

Moderate PEModerate PE Patients with moderate PE will present with transient hypotension, Patients with moderate PE will present with transient hypotension,

tachycardia, cardiac dysrhythmia, apprehension, tachypnea with tachycardia, cardiac dysrhythmia, apprehension, tachypnea with ↓↓ O O22 and and ↑ ↑ COCO22, and possible signs of pulmonary infarction. EKG will show acute , and possible signs of pulmonary infarction. EKG will show acute right axis deviation, nonspecific ST and T wave changes, and possible right axis deviation, nonspecific ST and T wave changes, and possible RBBB. Initial intervention with heparin therapy should be started in RBBB. Initial intervention with heparin therapy should be started in patients where diagnosis is probable and where there are no likely patients where diagnosis is probable and where there are no likely alternative diagnoses. Consider lytic therapy for patients without recent alternative diagnoses. Consider lytic therapy for patients without recent surgery or vascular injury. surgery or vascular injury.

A D-dimer can be done in non-post-operative patients to rule out PE. If the A D-dimer can be done in non-post-operative patients to rule out PE. If the result is positive, a pulmonary angiography should be done to confirm the result is positive, a pulmonary angiography should be done to confirm the diagnosis. diagnosis.

If a diagnosis of PE is not confirmed by pulmonary angiography but If a diagnosis of PE is not confirmed by pulmonary angiography but patient has risk factors for PE, prophylactic-dose heparin should be patient has risk factors for PE, prophylactic-dose heparin should be continued. continued.

With a confirmed diagnosis of PE, continue heparin and add warfarin for With a confirmed diagnosis of PE, continue heparin and add warfarin for long-term treatment. If anticoagulation is contraindicated, consider an IVC long-term treatment. If anticoagulation is contraindicated, consider an IVC filter. filter.

DiscussionDiscussion

Catastrophic PECatastrophic PE Patients with catastrophic PE will present with cardiac arrest, Patients with catastrophic PE will present with cardiac arrest,

brady-arrhythmia, severe hypotension, circulatory collapse, or brady-arrhythmia, severe hypotension, circulatory collapse, or left heart failure. It generally occurs 7-10 days after injury or left heart failure. It generally occurs 7-10 days after injury or onset of clinical illness, when the embolus has matured and is onset of clinical illness, when the embolus has matured and is resistant to lysis. A large embolus is usually mobilized after resistant to lysis. A large embolus is usually mobilized after patient performs a Valsalva maneuver, resulting in immediate patient performs a Valsalva maneuver, resulting in immediate circulatory collapse and cardiac arrest. circulatory collapse and cardiac arrest.

Treatment consists of intubation with 100% oxygen, Treatment consists of intubation with 100% oxygen, cardiotonic agents, and large doses of heparin. cardiotonic agents, and large doses of heparin. • Consider Trendelenburg’s procedure (rarely performed and rarely Consider Trendelenburg’s procedure (rarely performed and rarely

successful) or cardiopulmonary bypasssuccessful) or cardiopulmonary bypass• If patient survives initial resuscitation, continue heparin and consider If patient survives initial resuscitation, continue heparin and consider

lytic therapy or IVC filter. lytic therapy or IVC filter. • Survival rate is minimal. Survival rate is minimal.

DiscussionDiscussionOther PE management optionsOther PE management options

Thrombolytics: t-PA, streptokinase, urokinase. Thrombolytics: t-PA, streptokinase, urokinase. • Contraindicated in patients with surgery in previous 10 Contraindicated in patients with surgery in previous 10

days, active bleeding, previous cerebrovascular accident, days, active bleeding, previous cerebrovascular accident, serious GI bleed in previous 3 mos.serious GI bleed in previous 3 mos.

• Given for hemodynamically unstable PE. Most effective Given for hemodynamically unstable PE. Most effective when initiated within hours. when initiated within hours.

• Should discontinue heparin while giving lytic therapy, Should discontinue heparin while giving lytic therapy, unless there is a life-threatening clot. unless there is a life-threatening clot.

DiscussionDiscussionOther PE management optionsOther PE management options

Inferior vena cava filter - indicated if:Inferior vena cava filter - indicated if:• Patient has an absolute contraindication to Patient has an absolute contraindication to

anticoagulant therapy (eg. recent surgery, anticoagulant therapy (eg. recent surgery, hemorrhagic stroke, significant recent/active hemorrhagic stroke, significant recent/active bleeding)bleeding)

• Patients with a history of massive PE in whom a Patients with a history of massive PE in whom a recurrent embolism may be fatalrecurrent embolism may be fatal

• Recurrent DVT during adequate anticoagulant Recurrent DVT during adequate anticoagulant therapytherapy

IVC FilterIVC Filter

QUESTIONS ??????QUESTIONS ??????

SummarySummary

PE carries a high mortality rate and should be high on the PE carries a high mortality rate and should be high on the differential for patients presenting with sudden shortness of differential for patients presenting with sudden shortness of breath. breath.

If anticoagulant therapy is not contraindicated, therapeutic-If anticoagulant therapy is not contraindicated, therapeutic-heparin should be initiated early with suspected PE.heparin should be initiated early with suspected PE.

V/Q scan, CT angiography, and D-dimer are diagnostic tools V/Q scan, CT angiography, and D-dimer are diagnostic tools for PE, however, each test has their own advantages and for PE, however, each test has their own advantages and disadvantages. disadvantages.

Pulmonary angiography continues to be the gold standard for Pulmonary angiography continues to be the gold standard for diagnosing PE. diagnosing PE.

Management of PE consists of initiating heparin and warfarin Management of PE consists of initiating heparin and warfarin simultaneously for the first 5-7 days, followed by long-term simultaneously for the first 5-7 days, followed by long-term treatment and prophylaxis with outpatient warfarin for 3 treatment and prophylaxis with outpatient warfarin for 3 months, 6 months, or indefinitely depending on patient’s risk months, 6 months, or indefinitely depending on patient’s risk factors for recurrent PE. factors for recurrent PE.

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