Pulmonary Thrombo-Embolism It is a blockage of the pulmonary artery or its tributaries by an embolus coming from DVT in 90% of cases, while the other 10% comes from the heart

The burden of PTE PM finding : 5% of hospital death are due to PTE While 40-50% who die in hospital were found to have DVT. This indicates that PTE is a common problem in hospital practice

Thromboembolism epidemiology 5 million DVT’s 900,000 PE’s 290,000 fatalities Heit J. Blood. 2005;106:910.

Thromboembolism is a disease of hospitalized patients 71% received no prophylaxis in prior 30 days 50% in nursing homes or <90 days post-discharge Heit Mayo Clin Proc 2001; 76:1102 Goldhaber Am J Cardiol 2004; 93:259

DVT Clinical Features Unilateral leg swelling & pain in the thigh & calf muscles O / E: The leg is swollen, tender, hot & pitting oedema is present.

Hypercoagulable State Virchow’s triad Advancing age Immobilization Stroke - cord injury Anesthesia Heart or lung failure Hyperviscosity Surgery Prior DVT Venous access Trauma Sepsis Vasculitis Venous Stasis Endothelial Injury Hypercoagulable State Cancer Estrogen Family history Sepsis HIT Protein C, S or AT III deficiency Activated protein C resistance (Leiden) Hyperhomocystenemia Antiphospholipid antibody Prothrombin 20210 mutation

Venous thromboembolism 5-30%? 90% ~50% ~50% ~10% 63-70% of fatal PE’s unsuspected during life Stein Chest 1995; 110:978 Sandler J R Soc Med 1989; 82:203

Clinical Presentation Clinical features of DVT Clinical features of the type of PTE 1. MassivePTE 2. Less massive PTE 3. Pulmonary infarction 4. Recurrent small pulmonary emboli

Diagnosis Clinical (DVT, Type, Suspect) Radiological (CXR, PCTA, Cath) ECG ECHO Radioactive scan (V/Q) Lab. Investigation (D-dimer)

Clinical prediction rules Factor points Signs and symptoms of DVT 3 Alternate diagnosis less likely 3 Pulse >100 1.5 Immobilization / surgery w/i 4 wk 1.5 Previous DVT/PE 1.5 Hemoptysis 1 Malignancy 1 High > 6 (50%), Moderate 2-6 (19%), Low <2 (2%) Wells Ann Intern Med 1998; 129, 997

Diagnosis Clinical (DVT, Type, Suspect) Radiological (CXR, PCTA, Cath) ECG ECHO Radioactive scan (V/Q) Lab. Investigation (D-dimer)

Management A. Prevention: 1. Early postoperative mobilization 2. Correct faulty posture 3. Exercise during long journey 4. treatment of dehydration & CHF 5. IVC emboli prevention 6. Prophylaxis B. Treatment of established PTE

Treatment of established PTE