PULMONARY EMBOLISM

SIGN & SYMPTOM [THEORY]Symptoms SignsDyspnea(73%)Pleuritic chest pain(66%) Cough(37%)Hemoptysis(13%)

Tachypnea(70%)Rales(51%)Tachycardia(30%) Fourth heart sound(24%) Accentuated pulmonic component of the second heart sound(23%)

seizures, syncope, abdominal pain, fever, productive cough, wheezing, decreasing level of consciousness, new onset of atrial fibrillation

fever(14%)< 39?c>, chest wall tenderness

DDx.

MI ,Cardiac temponade ,Aortic dissection ,severe MR ,Pericardial effusion

Esophageal rupture Spontaneus

pneumothorax ,Pneumonia ,Pulmonary embolism

INVESTIGATION

Physical examination Sign of DVT ,PE

Basic testing CBC ,E’lyte ,BUN ,Cr ,CXR ,EKG

Pulmonary angiogram D-Dimer CT scan /MRI Ventilation-perfusion scan Venous doppler study

CXR

Initial CxR always NORMAL May show – Collapse, consolidation, small pleural effusion, elevated diaphragm.

EKG

PULMONARY ANGIOGRAPHY

CT SCAN

PERFUSION SCAN

Perfusion Mismatch Ventilation

แนวทางการประเมิ�นผู้��ป�วย

INVESTIGATE OF Pt.

Basic lab : CBC ,E’lyte ,BUN ,Cr LFT Coagulogram ,D-dimer CXR ,CT pulmonary ,Blood gas U/S whole Abd. U/S doppler leg EKG ,Echo ,TEE CEA ,Mammogram for cancer screening test

DEFINITE DX.

Pulmonary embolism

CAUSES

Pulmonary embolus is the end result of a deep vein thrombosis or blood clot elsewhere in the body. Most commonly deep vein thrombosis' are seen in the leg, but can also occur in veins within the abdominal cavity or in the arms.

RISK FACTORProlonged immobilization

Extended travel , prolonged bed rest Increased blood clotting potential

Medication ,smoking ,Cancer ,Pregnancy ,Surgery ,Polycythemia ,genetic predisposition

Damage to vessel wallTrauma with or without surgery or

casting

PICTURE OF BLOOD CLOT IS FORMED

INDICATION FOR ADMISSION

Severity of illness & RiskSign & symptomTreatment

Surely appropriate

TREATMENT [Theory]

Anticoagulation (clot-preventing medication) Heparin/LMWH ,Coumadin

Thrombolysis (clot-dissolving medication) Streptokinase ,t-PA

Surgical managementPulmonary thrombectomy

Inferior vena cava filter

การแบ่�งประเภท & การร�กษาSyndrom

eRt. ventricular

dysfunctionอาการนำ�า

การร�กษา

Massive Breathlessnesssyncope cyanosis Hypotension การอุ�ดตั�น >50 %

มิ� Heparin ร�วมิก�บ่thrombolytic therapy หร�อุ mechanical intervention

Moderate ถึ!ง largepulmonary infarction

ความิด�นโลห�ตัปกตั�Perfusion decrease >30%

มิ� Heparin+-thormbolytic therapy or mechanical intervention

การแบ่�งประเภท & การร�กษาSyndrom

eRt.

ventricular dysfunction

อาการนำ�า

การร�กษา

small ถึ!ง moderatepulmonary infarction

ความิด�นโลห�ตัปกตั�Pleuritic chest pain, hemoptysis, pleural rub or lung consolidation; peripheral emboli

ไมิ�มิ�/พบ่น�อุย

HeparinHeparin & NSAIDs

การแบ่�งประเภท & การร�กษาSyndrome Rt.

ventricular dysfunction

อาการนำ�า

การร�กษา

Paradoxical embolism

Sudden systemic emboli event such as stroke

พบ่น�อุย Anticoagulant +closure of right-to-left cardiac

Nonthrombotic embolism

ส่�วนใหญ่�เป*น air, fat, tumor fragments หร�อุ amniotic fluid

พบ่น�อุย ร�กษาแบ่บ่ประค�บ่ประคอุง

ส่ร�ปแนวทางการร�กษาภาวะ ACUTE PULMONARY EMBOLISM

IVC FILTER

If anticoagulant therapy is contraindicated and/or ineffective

TREATMENT [Pt.]

Anticoagulation Clexane Orfarin

LOS

ICD 9 code 415.1 Pulmonary embolism & infarction LOS 4.6 days

Pt.admit 6 days [ in ICU 1 day ]