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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
- 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
- CT pulmonary angiogram
- Pulmonary angiogram
Management
- Heparin
- V/Q scan
- If low probability and low clinical suspicion
- If low probability on scan but high clinical suspicion
- If intermediate probability on scan
- If high probabiltiy on scan
- 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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