1. Pulmonary Embolism & DVTBy
Prof. Dr. Abdul Hameed AI Qaseer

2. Definition It indicates occlusion of pulmonary artery
by exogenous or endogenous material that travels to the lung through the pulmonary circulation , causing potential spectrum of consequences,

3. Introduction Pathophysiology Risk Factors Symptoms Lab Findings
Radiology Findings
Treatment
Prevention

4. Risk Factors for PE and DVT
Immobilization
Surgery within the last 3 months
Stroke
History of venous thromboembolism
Malignancy
Preexisting respiratory disease
Chronic Heart Disease
Age >60
Surgery requiring >30mins of anesthesia
Recent travel (past 2weeks, >4 hours)
Varicose veins
Superficial vein thrombosis
Central VV catheter/port/pacemaker
Additional RF in Women:
Obesity BMI >/=29
Heavy smoking (>25cigs/day)
Hypertension
Pregnancy

5. Pathophysiology Dislodgement of a blood clot:
Lower Extremities: 65% to 90%
Pelvic venous system
Renal venous system
Upper Extremity
Right Heart

6. Symptoms of P.E. Dyspnea(~ 73%) Pleuritic pain ( 66%) Cough ( 37%)
Hemoptysis (blood tinged/streaked/ pure blood) (~ 13%)
From PIOPED study .

7. Signs of P.E. Tachypnea ( 70%) Rales(51%) Tachycardia ( 30%) Hypoxia
Accentuated pulmonic component of S2 (23%)
Fever: T <102 F (39C) (14%)
Chest wall tenderness may be the only sign

8. Signs in Massive P.E.
“Massive PE”: hemodynamic instability with SBP <90 or a drop in baseline SBP by >/=40mmHg
Signs as before PLUS:
Acute right heart failure
Elevated J.V.P.
Right-sided S3
Parasternal lift

9. P.E. & Leg Symptoms
Most patients with P.E. do not have leg symptoms at time of diagnosis
Patients with leg symptoms may have asymptomatic P.E.

10. Differential diagnosis
Chronic PE
Acute minor PE
Acute massive PE
Chronic occlusion of pulmonary microvasculature ,RHF
Occlusion of segmental pulmonary artery--> infarction & sometimes pleural effusion
Major homodynamic effects ,reduction in cardiac output ,acute RHF
Pathophisology
Exertional dyspnea .Late symptoms of pulmonary hypertension or RHF .
Pleuritic chest pain ,restricted breathing ,haemoptysis
Faintness or collapse ,central chest pain ,apprehension ,severe dyspnea
Symptoms
May be minimal early in disease .Later RV heave ,loud split P Terminal RHF
Tachycardia ,pleural rub ,raised hemidiaphram ,crackles ,effusion ,low-grade fever
Major circulatory collapse ,tachycardia ,hypotension. high JVP ,RV gallop rhythm ,split P2 .Severe cyanosis ,low UO
Signs
Enlarged pulmonary artery trunk ,enlarged heart ,prominent RV
Pleuropulmonary opacities ,pleural effusion ,linear shadows ,raised hemidiaphragm
Usually normal .May be subtle oligaemia .
Chest x-ray
RV hypertrophy and strain
Sinus tachycardia ,right axis deviation
S1Q3T3 ,anterior T wave inversion ,RBBB
ECG
Exertional reduction in PaO2 or desaturation
May be normal or reduced PaCO2
Low PaO2 & low PaCO2 ,Metabolic acidosis
Arterial blood gases
Other causes of pulmonary hypertension
Pneumonia ,pneumothorax ,musculoskeletal chest pain
MI ,pericardial tamponade ,aortic dissection
Differential diagnosis

12. Differential Diagnosis

13. WELL`S Clinical prediction rule for Likelihood of PE

14. Lab & Radiologic Findings in P.E.
ABG
BNP
Cardiac Enzymes: Troponin
D-dimer
ECG
Echocardiography
CXR
Ultrasound with colour Doppler study of leg veins
V/Q Scan
Spiral CT scanning
Angiography

15. Lab Findings in P.E. (ABG)
Hypoxemia
Hypocapnia (low CO2)
Respiratory Alkalosis
Massive PE: hypercapnia, mix resp and metabolic acidosis (inc lactic acid)
Patients with RA pulse ox readings <95% are at increased risk of in-hospital complications, resp failure, cardiogenic shock, death

16. Lab Findings in P.E. (BNP)
BNP (brain natriuretic peptide)
Insensitive test{ sensitivity(60%) & specifity (62%)}
Patient’s with PE have higher levels than pts without, but not ALL patients with PE have high BNP
Prognostic value measure: if BNP >90 pg| ml associated with adverse clinical outcomes (death, CPR, mechanical vent, pressure support, thrombolysis, embolectomy),
One meta analysis revealed that BNP > 100 pg\ml or NT- proBNP > 600 pg\l increased mortality rate fold .

17. Lab Findings in P.E. (Troponin)
High in 30-50% of pts with large PE

18. Lab Findings in P.E. (D- dimer)
Degredation product of fibrin
>500 is abnormal
Sensitivity: High, 95% of PE pts will be positive
Specificity: Low

19. Lab Findings in P.E. (cont’d)
ECG
2 Most Common finding on ECG:
Nonspecific ST-segment and T-wave changes
Sinus Tachycardia
Historical abnormality suggestive of PE
S1Q3T3
Right ventricular strain
New incomplete RBBB

20. PE ECG

21. PE ECG

22. Classic ECG S1,Q3,T3

24. S1Q3T3!!!

25. RAD
Right Atrial Enlargement

26. Radiologic Findings in P.E.

27. Radiology Findings in P.E. (cont’d)
CXR:
Normal
Atelectasis and/or pulmonary parenchymal abnormality
Pleural Effusion
Cardiomegally

28. The CXR is read as “ normal” in up to 30% of pats
The CXR is read as “ normal” in up to 30% of pats. With angiographically proven PE (Mayo. 2008).
In some series , an elevated hemidiaphragm is the most common finding with acute PE .

29. Chest Radiography

30. What’s This???
Hampton’s Hump

31. How About This???
Westermark's Sign: an abrupt tapering of a vessel caused by pulmonary thromboembolic obstruction.
This CXR shows enlargement of the left hilum accompanied by left lung hyperlucency, indicating oligemia (Westermark's sign).

32. PE Chest x-ray

34. Radiology Findings in P.E. (cont’d)
Lower Extremity Ultrasounds
If DVT found then treatment is same if patient has a P.E.
Disadvantage:
If negative, patients with PE may be missed
If false positive (3%), unnecessary intervention

35. Radiology Findings in P.E. (cont’d)
CT Pulmonary Angiography (CT-PA)
Widely used
Institution dependent
Sensitivity (83%)
Specificity (96%): if negative, very low likelihood that pt has P.E.

36. Figure 19. 58 CT pulmonary angiogram
Figure CT pulmonary angiogram. The arrow points to a saddle embolism in the bifurcation of the pulmonary artery.
Downloaded from: StudentConsult (on 18 November :58 AM)
© 2005 Elsevier

37. Radiology Findings in P.E. (cont’d)
Pulmonary Angiogram
Gold Standard
Not easily accessible
Radiologist dependent

38. Pulmonary Angiography

39. Radiology Findings in P.E. (cont’d)
Echocardiogram
Increased Right Ventricle Size
Decreased Right Ventricular Function
Tricuspid Regurgitation
Rarely:
RV thrombus
Regional wall motion abnormalities that spare the right ventricle apex (McConnell’s Sign)

40. Deep Vein Thrombosis Diagnosis
Compression ultrasonography of femoral & popliteal veins, sensitive for proximal vein thrombosis but less sensitive for calf vein thrombosis
Impedance plethysmography
Contrast venography
Radionuclide venography

41. Contrast Venography Showing Ilio-femoral DVT
Left leg
Right leg

42. Inter-iliac collaterals
Radionuclide venography showing chronic iliofemoral DVT
Inter-iliac collaterals

44. Treatment of P.E. Respiratory Support: Oxygen, intubation
Hemodynamic Support: IVF, vasopressors
Anticoagulation
Thrombolysis
IVC Filter

45. Anticoagulation Start during resuscitation phase itself
If suspicion high, start emperic anticoagulation
Evaluate patient for absolute contraindication (i.e.: active bleeding)

46. Anticoagulation-1
Bed rest is not recommended for DVT unless substantial pain & swelling
PE diagnosed, in patient therapy with initial bed rest for 24 to 48 hrs : often recommended

47. Anticoagulation-2
APE (+):IV anticoagulation with LMW heparin , or standard, UF heparin should be initiated unless contraindicated
Not thrombolytic, but decreasing the thromboembolic burden
If the suspicion of PE is high, parenteral anticoagulation should be considered even before imaging

48. Anticoagulation-3 Warfarin can be initiated on day 1 of therapy
SC LMWH or weight-based UFH IV should be administered for at least 5 days until INR=2.0 to 3.0 for 2 consecutive days
With standard heparin, a PTT checked Q6h until it is =1.5 to 2.5 X control
Achieving a therapeutic a PTT within 24 hours ,reduce the risk of recurrence

49. Anticoagulation-4
VTE require long-term anticoagulation to prevent extension & recurrence
Documented VTE with transient risk factors should treat 3 to 6 months, but more extended treatment is appropriate when significant risk factors persist, idiopathic or previous episodes of VTE
D-dimer levels may help guide decisions about the duration of therapy

50. Management LMWH Prepared by depolymerization of unfractionated heparin
MW ,000 (Mean 1,500-5,000)
Better bioavailability
S/C once or twice daily dose
Longer half-life
More predictable dose response
Less risk of adverse bleeding events

52. Management Complications of heparin / LMWH
Major bleeding - 5% (less with LMWH)
Osteoporosis – heparin > 1 month during pregnancy
Thrombocytopenia - 3% ( platelet count < 100,000 cells/ mm3)

53. Management
Oral vitamin K antagonist (Warfarin) – started within 24 hours of heparin therapy
INR maintained between
Heparin is discontinued when warfarin has been given for 4 days and INR is > 2.0 for two consecutive days
Oral anticoagulants are continued for 3 months or longer

54. Thrombolysis Considered once P.E. diagnosed
If chosen, hold anticoagulation during thrombolysis infusion, then resumed
Associated with higher incidence of major hemorrhage
Indications: persistent hypotension, severe hypoxemia, large perfusion defects, right ventricular dysfunction, free floating right ventricular thrombus, paten foramen ovale
Activase or streptokinase

55. Complications of Thrombolytic Therapy
The most devastating complication :ICH
retroperitoneal & GI bleeding & bleeding from surgical wounds or sites of recent invasive procedures
Contraindications : intracranial, spinal, or ocular surgery or disease, recent major surgery or other invasive procedures, active or recent major bleeding, pregnancy, & clinically obvious risks of bleeding

56. IVC Filter Indication: Also:
Absolute contraindication to anticoagulation (i.e. active bleeding)
Recurrent PE during adequate anticoagulation
Complication of anticoagulation (severe bleeding)
Also:
Pts with poor cardiopulmonary reserve
Recurrent P.E. will be fatal
Patient’s who have had embolectomy
Prophylaxis against P.E. in select patients (malignancy)

57. Management IVC Filter
Simon Nitinol IVC Filter, Nickle & Titanium - MRI compatible

58. Embolectomy Surgical or catheter Indication:
Those who present severe enough to warrant thrombolysis
In those where thrombolysis is contraindicated or fails