MASSIVE PULMONARY EMBOLISMCASE PRESENTATION

DR SYED RAZA

• 35 years old lady teacher• Living with partner• Type I DM – on Insulin, Non smoker• OCP – 6 years• Suddenly collapsed on doorway while preparing to

leave for school.• Possible LOC , No head injury. Partner called for

the ambulance.

IN ER

• Denied any chest pain or palpitation• No history of leg pain or swelling

O/E Conscious , oriented Tachypnoec R/R 36/mt SpO2 – 84% RA HR 128/mt SR BP 94/56 mmHG

• Legs – No signs of DVT• CVS- Normal heart sounds, No rub, possible

systolic murmur left para sternal area• Chest- Lungs – possible decreased air entry

left lung but otherwise clear.• Abdomen and Neuro - Unremarkable

ECHO REPORT

• Grossly dilated RV• Severely hypo kinetic RV free wall• RV apex contracts well• PASP 55 mmHg• Rest normal

• Impression – Massive PE• Thrombolysed with ALTEPLASE • Progress :• BP improved, tachycardia settled and Sp02

normalised almost immediately.• Patient transferred to CCU

ROLE OF ECHO IN SUSPECTED PE

• Not indicated in all suspected PE patients• Not a diagnostic tool for PE (Indirect evidence

only)• Signs not specific for PE (low sensitivity and

specificity)• Should not be overused – findings may be

misleading

INDICATIONS

• Suspected massive PE• Patient haemo dynamically unstable• RV strain on ECG, rise in Troponin or BNP• Other modes of imaging not readily available• Patient pregnant and massive PE is suspected• Immediate Thrombolytic may be indicated• Follow up studies – To assess RV function and

pulmonary artery pressure

Findings – Acute Massive PE

• Dilated RV ( EDD > 30 mm, RV/LV > 1)• Akinetic RV free wall but the RV apex

contracts well (Mc Connel’s sign) – 77% sensitivity and 94 % specificity

• Raised PASP – not more than 60 mmHg• Free floating thrombus in RV (rare)

Findings – Chronic PE

• RV Hypertrophy > RV Dilatation • RV function – reasonable• PASP – more than 60 mmHg

CAUSES OF RV ENLARGEMENT

a. Tricuspid valve disease b. Severe Pulmonary Regurgitation c. ASD d. Pulmonary HPN – Primary and Secondary e. R V Infarction f. Arrhythmogenic RV Dysplasia

(Cardiomyopathy)

EVIDENCE

• Heparin vs Streptokinase - only small studies Strep: all survived Hep: Non survived

Alteplase vs Streptokinase (Alteplase more effective)

Thrombolytic Therapy in patients with stable blood pressure but RV dilatation/dysfunction - Controversial