EMBOLIC AND THROMBOEMBOLIC DISEASES

Aziza Al-Amri ..

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WHAT ARE THROMBOEMBOLIC DISEASES ?

They are caused when a blood vessel is obstructed by a blood clot (embolus) that has

been carried in the bloodstream from the site of its formation.

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CONT. TED

VTE

DVT

PE

PULMONARY EMBOLISM

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OBJECTIVES

• Definition• Incidence• Symptoms • Risk factors and causes• Clinical presentation• Complications• Exams and Tests• Treatment • Prevention• Case study

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WHAT IS PULMONARY EMBOLISM ?

In Other Words : PE is the sudden blockage of a major blood vessel (artery) in the lung, usually by a blood clot.

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WHAT HAPPENS? If a large blood clot blocks the artery in

the lung, blood flow may be completely stopped, causing sudden death.

A smaller clot reduces the blood flow and may cause damage to lung tissue.

if the clot dissolves on its own, it may not cause any major problems.

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WHERE DOES IT HAPPENS?

• It can happen anywhere in the lungs– But since more blood flows into the bases of the lungs

• Pulmonary Embolism is more in the lower parts

– And less in the upper portion

» As a result of gravity

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INCIDENCE

• 600,000 per year get PE In the US

• This results in 50,000-200,000 deaths per year.

Based on the estimates on 2012

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SYMPTOMS Begins suddenly .. Sudden shortness of breath. Sharp chest pain that is worse with cough or deep breath. A cough that brings up pink, foamy mucus. Rapid breathingcan also cause more general symptoms such as : anxiety sweating a lot feeling lightheaded fainting fast heart rate or palpitations.

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CAUSES

Blood clot in the leg that breaks loose and

travels to the lungs .

Deep vain thrombosis .

Other things can block the artery, such as tumors, air bubbles, amniotic fluid, or fat that is released into the blood vessels when a bone is broken. But these are rare.

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RISK FACTORS

Being inactive for long periods.

Recent surgery that involves the legs, hips, belly, or brain.

Some diseases, such as cancer, heart failure, stroke, or a

severe infection.

Pregnancy and childbirth (cesarean section).

Taking birth control pills or hormone therapy.

Smoking.

Older than 70

Extremely overweight (obese).

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PRESENTATION Most Common

Symptoms

Dyspnea at rest or with exertion

Pleuritic pain Cough >2-pillow orthopnea Calf or thigh pain Calf or thigh swelling Wheezing Rapid onset of dyspnea

Most Common Signs

Tachypnea Tachycardia Rales Decreased breath

sounds Jugular venous

distension

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COMPLICATIONS

Cardiac arrest and sudden death

Shock

Abnormal heart rhythms

Death of part of the lung, called pulmonary

infarction

Pleural effusion

Pulmonary hypertension

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EXAMS AND TESTS

Diagnosing pulmonary embolism is difficult,

because there are many other medical

conditions, such as a heart attack or an anxiety

attack, that can cause similar symptoms.

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EXAMS AND TESTS

1. D-Dimer: is a blood test that measures a substance that is released when a blood clot breaks up.

Elevated in thrombosis, malignancy, pregnancy, elderly, hospitalized patients.

Normal results can rule out PE.

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EXAMS AND TESTS

2.Electrocardiogram (ECG):Only 10% of patients can have the S1 Q3 T3 so not reliable .

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EXAMS AND TESTS

3.Chest Radiography:Not a sensitive or specific test for the diagnosis

of PE.Atelectasis, Pleural effusion, or a pulmonary

parenchymal abnormality is noted most commonly

Only a small portion of patients with PE have a normal CXR.

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CXR

• Westermark and Fleishner’s sign

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CXR

• Hamptons Hump sign

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EXAMS AND TESTS

4. CT Angiogram

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EXAMS AND TESTS

5.Pulmonary Angiography

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EXAMS AND TESTS

Pulmonary Angiography:

The “gold standard”

A negative pulmonary angiogram excludes

clinically relevant PE.

The risk of embolization in patients with a

negative angiogram is extremely low

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EXAMS AND TESTS

• More tests can be used , like what ?!

6. MRI

7. ABG “ sudden drop in O2 level”

8. Doppler ultrasound “reflected sound waves to

determine whether a blood clot is present in the large

veins of the legs”

9.Echo “detects abnormalities in the size of right

ventricle”

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AFTER DETERMINATION PE ..

Other tests can help guide treatment and suggest how well the pt. will recover :

• Brain natriuretic peptide: A blood test to check the level of the hormone( level heart under stress )• protein troponin:( level damage to the heart’s muscle )

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TREATMENT

Anticoagulant medications

If symptoms are severe and life-threatening, aggressive

treatment is needed

Thrombolytic medications ( risk of sever bleeding )

Remove the clot ( Embolectomy)

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If surgery or medicines are not options, is there other methods to prevent pulmonary embolism ?

YES !

Vena cava filter :

This filter can prevent blood clots in the leg or pelvic veins from traveling to the lungs and heart, may be permanent or removable.

PREVENTION

Exercise

Getting up out of bed as soon as possible after

an illness or surgery

Quit smoking

Wear compression stockings

CLINICAL CASE …

• A 25 year old white female reports to the Emergency Room because of sharp left sided chest pain and shortness of breath of one day duration. The patient was in excellent health until yesterday. She was awakened from her sleep by sharp left sided chest pain. The pain worsened with motion and deep breathing. The pain has been progressively increasing in severity and she now has severe left shoulder pain. She complains of shortness of breath and is very apprehensive about dying. She denies any cough, fever, sputum production or hemoptysis.

• She is married and had one normal delivery three years ago. She is currently on birth control pills. She has never been hospitalized except for labor and delivery. Review of systems are negative. She denies any past history of venous problems.

• She reveals having a similar transitory minor episode of chest pain approximately one year ago while she was in a vacation.

• She works as a computer programmer. She smokes one pack of cigarettes a day for the past eight years. She considers herself a social drinker.

ON PHYSICAL EXAMINATION

• BP=114/80 ; pulse 118 ; T= 37.0

• She appears to be in moderate respiratory distress. She is well developed and nourished.

• Pertinent findings include a RR of 30 and shallow breathing. There is dullness, decreased chest expansion and decreased breath sounds in the left base. There were no rales or rubs.

CONT.

• Abdomen, pelvic and rectal exams are normal.

• The extremities reveal no evidence of edema, cyanosis or clubbing.

• Patient has negative Homan's Sign.

• Joint exam revealed shoulder movements complete in range. No warmth or tenderness noted. The rest of the patient's joints are normal.

FOLLOWING TESTS WERE DONE :• ABG: FI02 .21 pH 7.39 PCO2 30 HCO3 20 PaO2 80 SaO2 95%No drop on Oxygen level

CXR reveals pleural effusion in the left base. The left diaphragm is elevated.

Shoulder x-ray is normal.

There was a small amount of fluid in the left pleural space.

Doppler exam revealed deep vein thrombosis of the left lung , why ?

This patient did have CTA performed, which confirmed presence of PE.

She was subsequently started on anticoagulation

THANK YOUAny questions?