Pulmonary Embolism

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Pulmonary Embolism


  • 2/3 of deep venous thrombosis (DVT) are asymptomatic

  • 1/3 - 1/2 of those develop pulmonary embolism (~10% patients)

  • Cause 15-20% of hospital deaths

Preceded by thrombosis, (shares same risk factors) usually deep venous thrombosis

Risks for pulmonary emboli

  • Intrinsic
    • genetic predisposition
    • acquired predisposition
      • e.g. malignancy
  • Extrinsic
    • prolonged bed rest / immobility

Symptoms

  • sudden onset
    • shortness of breath
    • exertional dyspnoea
  • Pleuritic chest pain
    • sharp
    • localised
    • worse on inspiration
  • haemoptysis

Signs

Mild PE

  • tachycardia (>100)
  • mild pyrexia
  • tachypnoea
  • +/- pleural rub
  • +/- pleural effusion
  • hypoxia / desaturation on exercise

Acute Major PE

  • severe dyspnoea
  • dull central chest pain
  • tachycardia
  • gallup rythm
  • raised JVP
  • may be sudden onset → syncope / death

Investigations

  • ECG
    • S1Q3T3
    • sinus tachycardia
    • atrial fibrillation
    • right axis deviation
    • +ve R in V1
    • right bundle branch block
  • CXR (rules out other causes)
    • wedge-shaped opacities
    • right ventricular dilatation
    • patchy oligaemia
  • ABG
    • reduced pO2
    • +/- reduced pCO2
  • Clotting screen
    • +ve for d-dimers
      • negative predictive value
    • thrombophilia screen
  • V/Q scan
    • mismatched defects
  • CT pulmonary angiogram
  • Pulmonary angiogram

Management

  • Heparin
  • V/Q scan
    • If low probability and low clinical suspicion
      • No PE
    • If low probability on scan but high clinical suspicion
      • pulmonary angiogram
    • If intermediate probability on scan
      • pulmonary angiogram
    • If high probabiltiy on scan
      • treat as PE
  • O2
  • Colloids
  • Anticoagulation
    • heparin until warfarinised
  • Thrombolysis
  • embolectomy
  • IVC filters

Long term

  • anticoagulation
    • 6 months if first time and no other risks
    • life long if multiple emboli / recurrent
    • in antiphospholipid syndrome ensure INR 3-3.5

Complications

  • Death
  • Hypotension and collapse
  • breathlessness & chest pain
  • haemoptysis
  • pulmonary hypertension
 

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