Case Report Pneumology Dr. David Tran A&E, FVHospital Medical meeting September 28 th, 2011

Female 26 years old Consults A&E on September 18 th for chest pain, cough with small amount of blood in the sputum during the night. Consults A&E on September 18 th for chest pain, cough with small amount of blood in the sputum during the night. Complains about shortness of breath for 2 or 3 days. Complains about shortness of breath for 2 or 3 days. She mentions a traffic accident 3 weeks ago without thoracic trauma (just a small trauma at the R knee) She mentions a traffic accident 3 weeks ago without thoracic trauma (just a small trauma at the R knee) She has been in close contact with a acute case of tuberculosis a few months ago. She has been in close contact with a acute case of tuberculosis a few months ago. No past medical history, she smokes 20 cig./day. No past medical history, she smokes 20 cig./day.

Physical examination Pulse 58/min, BP 100/60, RR 18/min., SpO2 100% (air), EVA 4/10, Glasgow 15. Pulse 58/min, BP 100/60, RR 18/min., SpO2 100% (air), EVA 4/10, Glasgow 15. Auscultation shows slight decreased mumure in the right base of the thorax, no rales, no crackles. Auscultation shows slight decreased mumure in the right base of the thorax, no rales, no crackles. There is no sign of chest trauma, the ribs are not painful at palpation, the abdomen is soft. There is no sign of chest trauma, the ribs are not painful at palpation, the abdomen is soft. The legs are not swollen, there is a splint on the right knee no pain at the right calf, no Homans sign. The legs are not swollen, there is a splint on the right knee no pain at the right calf, no Homans sign.

ECG

Chest Xray

Hematological results

Biochemical results

D. Dimeres results

After discussion with the patient She informed us that she had bed rest for almost 3 weeks after her accident due to the immobilization of the right leg in a splint. She informed us that she had bed rest for almost 3 weeks after her accident due to the immobilization of the right leg in a splint. She received no anticoagulation during this time. She received no anticoagulation during this time. She has no personnal or familial history of thrombosis. She has no personnal or familial history of thrombosis. S he uses to smoke about 20 cig./day and takes oral contraceptive pils for 2 years. S he uses to smoke about 20 cig./day and takes oral contraceptive pils for 2 years.

Angio CT scanner thorax

AngioCT scanner of the thorax

Treatment Perfalgan 1g + Morphin 3mg (scanner) Perfalgan 1g + Morphin 3mg (scanner) Lovenox 0.6ml (60mg) s/cut x 2 per day Lovenox 0.6ml (60mg) s/cut x 2 per day Start Coumadine 4mg the day after Start Coumadine 4mg the day after Check INR 48h to 72h after the onset of anti-vitK treatment. Check INR 48h to 72h after the onset of anti-vitK treatment. Contention socks Contention socks Hospitalized in medical ward (Dr Thai, cardiologist) Hospitalized in medical ward (Dr Thai, cardiologist)

DVT & Pulmonary Embolism 117 cases / persons in USA (increases with the age) 117 cases / persons in USA (increases with the age) Importance of risk factors (immobilization, contraceptive drugs, flight travel, familial or personal past history) Importance of risk factors (immobilization, contraceptive drugs, flight travel, familial or personal past history) Most clinical PE originate from a proximal DVT from the legs above the knee (popliteal, femoral or iliac vein) Most clinical PE originate from a proximal DVT from the legs above the knee (popliteal, femoral or iliac vein) As many patients have intermediate probability of venous thrombosis, clinical jugement is still the cornerstone of the diagnosis. As many patients have intermediate probability of venous thrombosis, clinical jugement is still the cornerstone of the diagnosis.

Risk factors

D-Dimer tests D-Dimer are very sensitive but have a very low specificity (Good negative predictive value) D-Dimer are very sensitive but have a very low specificity (Good negative predictive value) D-Dimer can rule out the diagnosis of PE in only 5% of patients aged > 80 years (60% in young patients 80 years (60% in young patients < 40 years old) Low risk of DVT assessment by validated prediction score and a negative D-dimer test (Latex agglutination) is deemed to rule out the diagnosis of DVT. Low risk of DVT assessment by validated prediction score and a negative D-dimer test (Latex agglutination) is deemed to rule out the diagnosis of DVT. D-Dimer positive result does not raise the likelihood of DVT and has therefore limited clinical value alone. D-Dimer positive result does not raise the likelihood of DVT and has therefore limited clinical value alone.

Clinical probability score (Geneve Score)

Wells score of probability for PE

Assess clinical probability

Use of d-dimer and angio-CT for the diagnosis of Pulmonary Embolism

Decisional algorithm for the diagnosis of PE

CT pulmonary angiography (Se 83%, Sp 96%)

Principle of PE treatment Immediate full anticoagulation is mandatory for all patients suspected of having have DVT or pulmonary embolism. Immediate full anticoagulation is mandatory for all patients suspected of having have DVT or pulmonary embolism. Diagnostic investigations should not delay empirical anticoagulant therapy. Diagnostic investigations should not delay empirical anticoagulant therapy. Current guidelines recommend starting unfractionated heparin (UFH), low–molecular weight heparin (LMWH), or fondaparinux (all grade 1A) in addition to an oral anticoagulant (warfarin) at the time of diagnosis Current guidelines recommend starting unfractionated heparin (UFH), low–molecular weight heparin (LMWH), or fondaparinux (all grade 1A) in addition to an oral anticoagulant (warfarin) at the time of diagnosis Discontinue UFH, LMWH only after the international normalized ratio (INR) is 2.0 for at least 24 hours, but no sooner than 5 days after warfarin therapy has been started (grade 1C recommendation). Discontinue UFH, LMWH only after the international normalized ratio (INR) is 2.0 for at least 24 hours, but no sooner than 5 days after warfarin therapy has been started (grade 1C recommendation).

Curative Treatment Low molecular weight heparin (LMWH) Low molecular weight heparin (LMWH) LOVENOX 0.1ml/10Kg sub-cut twice a day LOVENOX 0.1ml/10Kg sub-cut twice a day Early relay with anti-vitamin K by mouth Early relay with anti-vitamin K by mouth INR after 48-72h of treatment INR after 48-72h of treatment Stop Heparin when INR 2< <4 at 2 times Stop Heparin when INR 2< <4 at 2 times Duration of efficient anticoagulation minimum 3 to 6 months (according persistent risk factors) Duration of efficient anticoagulation minimum 3 to 6 months (according persistent risk factors)

Think to Pulmonary Embolism!