Pulmonary embolism: Difference between revisions
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===Types===
===Types===
====Massive====
{{PE types}}
#Sustained hypotension (sys BP <90 for at least 15min or requiring inotropic support)
#Pulselessness
#Persistent profound bradycardia (HR <40 with signs of shock)
====Submassive====
#Sys BP >90 but with either RV dysfunction or myocardial necrosis
#RV dysfunction
##RV dilation or dysfunction on TTE
##RV dilation on CT
##Elevation of BNP (>90)
##ECG: new complete or incomplete RBBB, anteroseptal ST elevation/depression or TWI<ref>David Da Costa. Bradycardias and atrioventricular conduction block BMJ. 2002 March 2; 324(7336): 535–538 </ref>
##Myocardial necrosis: Troponin I >0.4
====Non-Massive====
*No hemodynamic compromise and no RV strain
====Sub-Segmental====
*Limited to the subsegmental pulmonary arteries


==Clinical Presentation==
==Clinical Presentation==

Revision as of 04:08, 7 November 2014

See Pulmonary Embolism in Pregnancy for pregnancy specific information.

Background

Clinical Spectrum of Venous Thromboembolism

Clinical Spectrum of Venous thromboembolism

Only 40% of ambulatory ED patients with PE have concomitant DVT[1][2] Only 40% of ambulatory ED pts w/ PE have concomitant DVT

Types

Pulmonary Embolism Categorization[3]

Massive: High-risk

Hemodynamically unstable with symptoms of shock

  • ACCP 2016 CHEST Guidelines: Sustained hypotension ONLY criteria (systolic BP <90 for at least 15min or requiring inotropic support)
  • Previous definitions (e.g. AHA 2011) include cardiac arrest/pulselessness or persistent profound bradycardia (HR <40 with signs of shock)

Submassive: Intermediate-risk

Right ventricular dysfunction (RVD) and/or myocardial necrosis in the absence of persistent hypotension or shock (SBP >90)[4]

  • RV dysfunction
    • RV dilation or dysfunction on TTE
      • "D Sign" on bedside echo (LV takes on a "D" shape due to RV dilation)
    • RV dysfunction on CT defined as RV/LV ratio >0.9[5]
    • Elevation of BNP (>90)
    • ECG findings of right heart strain (see diagnosis below)
  • Myocardial necrosis: Troponin I >0.4

Non-Massive: Low-risk

No hemodynamic compromise and no RV strain

Sub-Segmental

  • Limited to the subsegmental pulmonary arteries

Clinical Presentation

Symptoms

According to the PIOPED II study, these are the most common presenting signs[6]

Signs

  • Tachypnea (54%)
  • Calf or thigh swelling, erythema, edema, tenderness, palpable cord (47%)
  • Tachycardia (24%)
  • Rales (18%)
  • Decreased breath sounds (17%)
  • Accentuated pulmonic component of the second heart sound (15%)
  • JVD (14%)
  • Fever (3%)

Diagnosis

Wells Criteria

  1. Symptoms of DVT - 3pts
  2. No alternative diagnosis better explains the illness - 3pts
  3. HR > 100 - 1.5 pts
  4. Immobilization within prior 4wks - 1.5pts
  5. Prior history of DVT or PE - 1.5pts
  6. Active malignancy - 1pt
  7. Hemoptysis - 1pt

Wells Score

  1. 0-1 point: Low probability (3.4%)
  2. 2-6 points: Moderate probability (27.8%)
  3. 7-12 points: High probability (78.4%)

Workup by Probability

Low Probability

Moderate Probability

  • Obtain d-dimer

High Probability

  • Consider anticoagulation before imaging!
  • CTPA if GFR >60
  • V/Q if GFR <60

Differential Diagnosis

Chest pain

Critical

Emergent

Nonemergent

Treatment

Supportive care

  • Give IVF to increase preload

Anticoagulation

  • Indicated for all patients with confirmed PE or high clinical suspicion (don't wait for imaging)
  • Treatment options:
    • LMWH SC
      • 1st line for most hemodynamically stable pts
      • contraindicated in renal failure
      • Enoxaparin 1 mg/kg SC q12h
      • Dalteparin 200 IU/kg SC q24h, max 18,000 IU
    • Unfractionated Heparin
      • Consider in pts w/:
        • Persistent hypotension
        • Increased risk of bleeding
        • Recent sx/trauma
        • Renal failure (GFR <30)
        • Morbid obesity or anasarca (poor sc absorption)
        • Thrombolysis is being considered
      • 80 units/kg bolus; then 18 units/kg/hr
        • Check PTT after 6hr; adjust infusion to maintain PTT at 1.5-2.5x control

Thrombolysis

Major controversy exists regarding thrombolytic therapy in submassive PE. Therapy should be individualized to patients.[7][8][9] The mortality benefit may be greatest in patients with right ventricular dysfunction [10]

Indications

  1. Patients with massive PE and acceptable risk of bleeding complications
  2. Pt w/ submassive PE w/ evidence adverse prognosis + low risk of bleeding complications
    1. Hemodynamic instability
    2. Worsening respiratory insufficiency
    3. Severe Right Ventricular dysfunction
    4. Major myocardial necrosis

Thrombolytic Instructions

  1. Review contraindications
  2. Discontinue heparin during infusion
  3. tPA 100mg over 2hr OR 0.6 mg/kg over 2min
  4. After infusion complete measure PTT
    1. Once value is <2x upper limit restart anticoagulation

Absolute contraindications

  1. Any prior intracranial hemorrhage,
  2. Known structural intracranial cerebrovascular disease (e.g. AVM)
  3. Known malignant intracranial neoplasm
  4. Ischemic stroke within 3mo
  5. Suspected aortic dissection
  6. Active bleeding or bleeding diathesis
  7. Recent surgery encroaching on the spinal canal or brain
  8. Recent closed-head or facial trauma w/ radiographic evidence of bony fx or brain injury

Relative contraindications

  1. Age >75 years
  2. Current use of anticoagulation
  3. PE in Pregnancy
  4. Noncompressible vascular punctures
  5. Traumatic or prolonged CPR (>10min)
  6. Recent internal bleeding (within 2 to 4 weeks)
  7. History of chronic, severe, and poorly controlled hypertension
  8. Severe uncontrolled HTN on presentation (sys BP >180 or dia BP >110)
  9. Dementia
  10. Remote (>3 months) ischemic stroke
  11. Major surgery within 3 weeks

IVC Filter

  • Indications
    • anticoagulation contraindicated in pt with PE
    • failure to attain adequate anticoagulation during treatment

See Also

Thrombolytics for pulmonary embolism

External Links

References

  1. ↑ Righini M, Le GG, Aujesky D, et al. Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial. Lancet. 2008; 371(9621):1343-1352.
  2. ↑ Daniel KR, Jackson RE, Kline JA. Utility of the lower extremity venous ultrasound in the diagnosis and exclusion of pulmonary embolism in outpatients. Ann Emerg Med. 2000; 35(6):547-554.
  3. ↑ Jaff MR et al. Management of massive and submassive pulmonary embolism, ileofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011 Apr 26;123(16):1788-830. doi: 10.1161/CIR.0b013e318214914f. Epub 2011 Mar 21
  4. ↑ Martin C et al. Systemic thrombolysis for pulmonary embolism: a review. P T. 2016 Dec; 41(12):770-775
  5. ↑ Becattini C et al. Multidetector computed tomography for acute pulmonary embolism: diagnosis and risk stratification in a single test. Eur Heart J. 2011 Jul;32(13):1657-63. doi: 10.1093/eurheartj/ehr108. Epub 2011 Apr 18.
  6. ↑ Stein PD et al. Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. Am J Med. 2007;120(10):871.
  7. ↑ Elliott C. et al. Fibrinolysis of Pulmonary Emboli — Steer Closer to Scylla.
  8. ↑ Sharifi M et al. Moderate pulmonary embolism treated with thrombolysis (from the “MOPPETT trial). J Cardiol 2013; 111: 273-7
  9. ↑ Meyer G. Fibrinolysis for patients with intermediate-risk pulmonary embolism. NEJM 2014; 370(15): 1402-1411
  10. ↑ Chatterjee. S et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 2014; 311(23):2414-21. PubMed ID: 24938564.
  • Circulation. 2011 Apr 26;123(16):1788-830
  • Tintinalli
  • D-Dimer Concentrations in Normal Pregnancy: New Diagnostic Thresholds Are Needed. Kline et all. Clinical Chemistry May 2005 vol. 51 no. 5 825-829 http://www.clinchem.org/content/51/5/825.long
  • UpToDate
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