1. 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

2. 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

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

4. 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

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

6. 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 mutation

7. 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

8. 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

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

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

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

12. 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

13. Treatment of established PTE