pulmonary embolism

Download Pulmonary embolism

Post on 09-Jan-2016

65 views

Category:

Documents

0 download

Embed Size (px)

DESCRIPTION

Pulmonary embolism. Pulmonology Refresher Course 27 May 2011 Dr. JM Nel Department of Critical Care. Incidence. Pulmonary embolism (PE) In 1% of patients admitted to hospital Accounts for 5% of in hospital deaths Common mode of death Cancer Stroke - PowerPoint PPT Presentation

TRANSCRIPT

  • Pulmonary embolismPulmonology Refresher Course27 May 2011

    Dr. JM NelDepartment of Critical Care

  • IncidencePulmonary embolism (PE)

    In 1% of patients admitted to hospitalAccounts for 5% of in hospital deaths

    Common mode of deathCancerStroke

    Most common cause of death in pregnancy

  • EtiologyMajority (75%)

    Propagation of lower limb DVTOther (rare)

    Amniotic fluidPlacentaAirFatTumourSeptic emboli (from endocarditis affecting tricupid or pulmonary valves)

  • Risk factorsSurgeryMajor abdominal/ pelvic surgeryHip/ knee surgeryPost- operative intensive care

    ObstetricsPregnancy/ puerperium

    Cardiorespiratory diseaseCOPDCongestive cardiac failureOther disabling diseaseLower limb problemsFractureVaricose veinsStroke/ spinal injury

    Malignant diseaseAbdominal pelvicAdvanced/ metastaticConcurrent chemotherapy

    MiscellaneousIncreasing agePrevious proven VTEImmobilityThrombotic disordersTrauma

  • Clinical featuresClinical features vary

    DIFFICULT DIAGNOSIS

  • Clinical featuresASK 3 QUESTIONS

    Is the presentation consistent with PE ?

    Does the patient have risk factors for PE ?

    Is there another diagnosis that can explain the patients presentation ?

  • Clinical featuresClinical features

    Acute massive PE

    Submassive PE

    Acute small/ medium PE

  • Acute massive PESymptoms

    CollapseCentral chest painSevere dyspnoeaSigns

    Major circulatory collapseTachycardiaHypotensionIncreased JVPLoud P2Parasternal heaveRV gallop rhythm

    Severe cyanosis

  • Acute small/medium PESymptoms

    Pleuritic chest painRestricted breathingHaemoptysis

    Signs

    TachycardiaPleural rubRaised hemidiaphragmCracklesEffusionLow- grade feverNormal BP

  • Submassive PE

    WHATS THAT ???

  • Submassive PEMassive PE

    RV Strain/dilatationLow BPSubmassive PE

    RV Strain/dilatationNormal BP

  • InvestigationsCXR

    ECG

    Arterial blood gas

    D- dimerHeart sonar

    Other biomarkers

    Imaging

  • Investigations: Chest x- rayHigh index of suspicion if normal CXRAcute dyspnoec and hypoxemic patient

    Exclude differential diagnosesHeart failurePneumoniaPneumothorax

  • Investigations: Chest x- rayRadiographic appearances

    Pulmonary opacities

    Wedge shaped opacity

    Horizontal linear opacities

    Pleural effusion

    Oligaemia of lung field

    Enlarged pulmonary artery

    Elevated hemidiaphragm

  • Investigations: Chest x- rayAcute massive PE

    Usually normalOligaemia

    Acute small/ medium PE

    Pleuropulmonary opacitiesPleural effusionLinear shadowsRaised hemidiaphragm

  • Investigations: ECGCommon but non- specific

    Most commonSinus tachycardia

    Exclude other differential diagnosesAcute myocardial infarctionPericarditis

  • Investigations: ECGMassive/Submassive PEAcute cor pulmonaleS1 Q3 T3T- wave inversionRBBBP-wave pulmonaleRight axis

    Small/ medium PE

    Sinus tachycardia

  • Investigations: A- blood gasTypical A- blood gas

    Low PaO2Normal or low PaCO2

  • Investigations: D- dimerDegradation product

    Positive D- dimerHigh negative predictive value

    Screening test for PE

    ELISA based D-dimer superior sensitivityOther causes for elevation

    Myocardial infarctionPneumonia/InfectionSepsisPregnancyMalignancyHospitalised patientsElderlyTrauma

  • Investigations: Heart sonarMassive/Submassive PE

    Acute dilatation of the right heartPulmonary hypertensionThrombus can be seen

    LOOK FOR: RV DYSFUNCTIONRV DYSFUNCTION

    RV enlargementHypokinesis of free wallLeftward septal shiftPHT

  • Investigations: Other biomarkersCardiac troponin

    Risk stratification

    Elevated in massive PE6-12 hours after symptoms

    Pro-BNP

    Increases with ventricular stretching

    But also elevated in other causes of PHT/congestive heart failureDetects myocardial dysfunction Detects myocardial injury

  • Investigations: Other biomarkersNormal levels:

    Low risk of death/complications

    Increased levels:

    Cannot predict early death

    RISK ASSESSMENT

    Do not dictate need for early thrombolysis

  • Investigations: ImagingV/Q scansIf normalExcludes PE

    If underlying chronic cardiopulmonary pathology (COPD, congestive cardiac failure)Majority of scan indeterminate

  • Investigations: ImagingCT pulmonary angiographyDifficult to detect small peripheral emboli

    Duplex doppler of legsDVT in leg

    Pulmonary angiographyGold standard

  • ManagementGeneral measures

    Anticoagulation

    Thrombolytic therapy

    Caval filters

  • Management: GeneralOxygen for hyoxaemic patientsKeep arterial oxygen saturation > 90%

    AnalgesicsOpiatesCareful in hypotensive patientsAvoid diuretics and vasodilators

    Treat hypotensionIVI fluidsInotropic agents of limited value

  • Confirmed PENOECHORV dysfunctionLow riskNon-massive PEYESAnticoagulateHemodynamicallyStable ?LMWHUFHNOYESMassive PEThrombolysis if no contra-indicationAnticoagulateSubmassive PE

  • Management: AnticoagulationStart immediately

    High or intermediate probability of PELow molecular weight heparin sc

    ClexaneGive according to weightReduces mortality in PEReduces the propagation of clot and risk of further emboliGive at least 5 daysStart WarfarinStop Clexane when INR is > 2

  • Management: AnticoagulationDuration of Warfarin therapyIf underlying prothrombotic risk or previous emboliFor life

    If identifiable and reversible risk factor3 Months

    If idiopathic 6 Months

  • Management: Thrombolytic therapyAcute massive pulmonary embolismPatient shockedImproves outcome

    If normal BPUnsure if advantage above heparin

    High risk of intracranial haemorrhageScreen patient for haemorrhagic risk

  • Management: Caval filtersFilter inserted in inferior vena cavaBelow origin of renal vessels

    IndicationsRecurrent PE despite adequate anticoagulationContraindication to anticoagulation

  • PrognosisLowest recurrence after operation

    If right ventricular dysfunctionRisk of cardiogenic shockIncreased risk of death

    If pulmonary hypertension and right ventricular dysfunction after 6 weeksIncreased risk to develop right heart failure over next 5 years

  • Pulmonary Embolism:Case Studies

  • Pulmonary embolism Case Presentation 1:64 year old male Previous hip surgery 20 days agoSudden dyspnoeaPleuritic chest painHypoxicBP 130/80Clinically DVT

  • Pulmonary embolismDIFFERENTIAL DIAGNOSIS

    Pulmonary embolism

    Pneumonia

    Pneumothorax

    Musculoskeletal chest pain

  • Pulmonary embolismASK 3 QUESTIONS

    Is the presentation consistent with PE ?

    Does the patient have risk factors for PE ?

    Is there another diagnosis that can explain the patients presentation ?

  • Pulmonary embolism

    WHAT NOW ???

  • Pulmonary embolismCXRExclude differential diagnosesHeart failurePneumoniaPneumothorax

    High index of suspicion if normal CXRAcute dyspnoeac and hypoxaemic patient

  • Pulmonary embolismECG Exclude other differential diagnosesAcute myocardial infarctionPericarditis

    Most commonSinus tachycardia

  • Pulmonary embolismArterial bloodgas

    Low PaO2

  • Pulmonary embolismD- dimer

    POSITIVE

  • Pulmonary embolismHeartsonar

    NORMALMassive/Submassive PE

    Acute dilatation of the right heartPulmonary hypertensionThrombus can be seen

    Alternative diagnoses

    Left ventricular failureAortic dissectionPericardial tamponade

  • Pulmonary embolismDuplex doppler of legs

    DVT in leg

  • Pulmonary embolismV/Q scan

    PULMONARY EMBOLISM

  • Pulmonary embolism: ManagementGeneral measuresOxygen for all hyoxaemic patientsKeep arterial oxygen saturation > 90%

    AnticoagulationClexane 80mg bd scGive at least 5 days

    Warfarin

    Stop Clexane when INR is > 2

  • Pulmonary embolism: ManagementHOW LONG DO I TREAT THIS PATIENT WITH WARFARIN ???

    3 MonthsDuration of Warfarin therapyIf underlying prothrombotic risk or previous emboliFor life

    If identifiable and reversible risk factor3 Months

    If idiopathic 6 Months

  • Pulmonary embolismCase Presentation 2:28 year old ladyOral contraceptives10 hour flightSudden dyspnoeaBP 90/40Loud P2/ Increased JVPHypoxic

  • Pulmonary embolismDIFFERENTIAL DIAGNOSISMassive pulmonary embolism

    Myocardial infarction

    Pericardial tamponade

    Aortic dissection

  • Pulmonary embolismCXR

    NORMAL

  • Pulmonary embolismECGS1 Q3 T3RBBB

    Arterial bloodgasLow PaO2

    D- dimerPOSITIVE

  • Pulmonary embolismHeartsonarRight ventricular dilatationIncreased pulmonary pressure

  • Pulmonary embolismCT pulmonary angiography

    MASSIVE PULMONARY EMBOLISM

  • Pulmonary embolism: ManagementGeneral measuresOxygen for all hypoxaemic patientsKeep arterial oxygen saturation > 90%Treat hypotension with IVI fluids

    Thrombolytic therapyRV dilatationLow BP

  • Pulmonary embolism: ManagementComplications of thrombolytic therapy

    Intracranial haemorrhageHaemorrhage at other sitesAnaphylaxis

  • Pulmonary embolismCase Presentation 3:28 year old ladyOral contraceptives10 hour flightSudden dyspnaeBP 130/80Loud P2/ Increased JVPHypoxic

  • Pulmonary embolismCXR

    NORMAL

  • Pulmonary embolismECGS1 Q3 T3RBBB

    Arterial bloodgasLow PaO2

    D- dimerPOSITIVE

  • Pulmon