Pulmonary embolism is an emergency condition adn its management is very crucial. i tried to cover this topic in this presentation. I hope it helps you somehow.

3. Case Scenario :
35yr old female bed
bound for 2 weeks,
complains of sudden
shortness of breath
and chest pain

4. Differential Diagnosis
 Pulmonary embolism
 Acute coronary syndrome
 Ccf and pulmonary edema
 Non cardiogenic pulmonary
edema
 Cardiac temponade
 Pneumothorax

5. Provisional Diagnosis:
 PULMONARY EMBOLISM

6. What Pulmonary
Embolism is…???
Venous thrombosis in pelvis/legs
Clot breaks off
Passes through veins
Reaches right heart
Lodges in pulmonary circulation

8. Causes:
 DVT( 80%)
 Septic emboli
 Tumour
 Embolisms… Fat, Air, Amniotic
fluid
 Parasites

9. Risk Factors:
 Surgery; Abdominal, Pelvic, Hip,
Knee, ICU
 Obstetrics; Pregnancy,
Puerperium, HRT, OCP
 CVS: COPD, CCF
 Lowe limb; Fractures, Varicose
veins, Stroke
 Malignant diseases; Abdominal,
Pelvic carcinoma
 Miscellaneous; Increasing age,
Immobility, Trauma, Thrombotic
disorders

10. Clinical Types:
 1. Acute Massive PE
 2. Acute Small/Medium PE
 3. Chronic PE

11. ACUTE MASSIVE PE
 Symptoms: Faintness, Crushing
centeral chest pain,
apprehension, severe dyspnoea
 Signs: Tachycardia,
Hypotension, Incearsed JVP, RV
gallop rhythm, Loud P2, severe
cyanosis, Decreased urinary
output
 ALTERNATIVE DIAGNOSIS:
MI, PERICARDIAL
TAMPONADE,
AORTIC
DISSECTION

12. ACUTE SMALL PE
 Symptoms: Pleuritic chest pain,
Restricted breathing,
Haemoptysis
 Signs: Tachycardia, Pleural rub,
Raised hemidiaphragm, Crackles,
Low grade fever, Effusion
 Alternative Diagnosis:
PNEUMONIA,
PNEUMOTHORAX,
MUSCULOSKELETAL
CHEST PAIN

13. CHRONIC PE
 Symptoms: Exertional dysponea,
Pulmonary Hypertension, Right
heart failure
 Signs: Minimal early in disease,
Later on RV heave, Loud P2

15. PE:

16. PE in Special
Circumstances:
PREGNANCY:
 Common mode of death
 CTPA can be performed but with
FETAL SHIELDING
 Warfarin is TERATOGENIC, so
treated with LMWH

17. Continued…
Old age:
 Risk rises with increasing age
 Prophylaxis given to all with acute
illness except those with ACUTE
STROKE
 Long term anticoagulation therapy
not required

18. Continued…
Air Travel:
 Supposed risk of DVT and
subsequent PE associated with
air travell… ECONOMY
CLASS
SYNDROME

19. Investigations:
 FBC
 U&E
 Baseline clotting profile

20. Chest Xray:

21. ECG

22. ABGs:
 Reduced PaO2
 Normal or Low PaCO2

23. D-DIMER:

24. CTPA:

25. Others:
 Troponin I
 Brain Natriuretic Peptide
 Echocardiography
 Ventilation Perfusion Scanning

26. Emergency
Management:
O2 100%
Morphine 10 mg with
anti emetic
Thrombolysis(50 mg
bolus of ALTEPLASE)
OR surgery
IV access and
start heparin

27. Continued…
What is systolic BP?
< 90 mmHg
Rapid colloid infusion
500 ml
BP still low
Dobutamine 2.5-
10microgram/kg/min
IV
>90mmHg
Start warfarin
Conform diagnosis
BP still low
NOR
ADRENALI
NE
BP still low
Clinically
definate PE &
no CI

28. FURTHER
MANAGEMENT:
 Continue Heparin/Fondaparinux
for atleast 5 days
 INR monitoring
 LMWH continued till INR is 2 or
more for atleast 24hours
 Now shift patient to Oral
Anticoagulant… Warfarin
 INR monitoring
 Thrombin or Activated factor X
inhibitors can also be give…
NEED NO MONITORING

29. Rx For How Long…
1.REVERSIBLE RISK
FACTOR:
For 3months
2.PERSISTENT RISK
FACTOR/PERVIOUS PE:
Life long therapy
3. CANCER ASSOCIATED
VTE:
LMWH for 6months, then Warfarin
4. UNPROVOKED VTE:
3months

30. SURGICAL
INTERVETION:
 Pulmonary Embolectomy
 Caval Filters

31. PREVENTION:
 Heparin
 Compression stockings
 Early mobilization after surgery
 Stop HRT
 If family history positive for PE,
rule out THROMBOPHILIA