Pulmonary embolism

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Pulmonary thrombo-embolism is an important cause of morbidity and mortality, especially among the hospitalized patients.  A vast majority of clinically significant pulmonary emboli (PE) arises from deep venous thrombosis.

Predisposing Factors

  • Venous disease of the lower extremities.
  • Cancer.
  • Heart failure.
  • Recent major surgery.
  • Prolonged immobilization.
  • Paralysis.
  • Strong family history of thrombosis.
  • Pregnancy.

Symptoms

  • Dyspnoea
  • Pleuritic chest pain
  • Apprehension
  • Cough

Physical Findings

  • Tachypnoea
  • Tachycardia
  • Inspiratory crackles
  • Swelling of calf
  • Localized tenderness
  • Slight rise in local temperature suggests DVT.

Diagnosis of Thrombo-embolism

Diagnosis is based on Clinical suspicion and General Diagnostic Evaluation

  • Blood Complete Exam:  Leucocytosis
  • E.C.G – To rule out other cardiac causes of tachypnoea, tachycardia
  • Arterial Blood Gases:  (ABGs)
  • Arterial hypoxaemia usually accompanied with hypocapnia.
  • Normal PaO2 can occur in 14 % of patients with acute pulmonary embolism.
  • Specific Diagnostic Studies
  • Ventilation – perfusion (V-Q) lungs scan is indicated in all clinically stable patients with suspected pulmonary embolism.
  • Pulmonary Angiography for confirmation & diagnosis and thrombolytic therapy.  These facilities are presently available only at a few centers including Punjab Institute of Cardiology.
  • X-Ray Chest       Absence of vascular marking on the affected side

 

TREATMENT

A- Supportive Care:-Oxygen Therapy

B- Prevention of Recurrent Emboli is the major therapeutic goal.

Anticoagulation: Heparin I/V.  A bolus of heparin (80 units/kg) followed by continuous infusion (18 units/kg/hr) titrated individually to achieve an activated partial thromboplastin time (aPTT) between 1½ and 2½ times the control value, continued for 5-10 days.  If APTT is not available, clotting time should be monitored with the help of capillary tubes at 2-3 times the baseline level

  • Oral warfarin can be given with the initiation of heparin. Starting dose 5 mg / day for first 2 days, followed by daily dose adjusted to the international normalized ratio (INR) of 2.0-3.0.  Warfarin should be continued for 3 months.
  • I/V heparin should be started immediately on basis of clinical suspicion of PE and without waiting for definitive studies to be obtained.

C- Specific Therapy

  • Systemic thrombolytic therapy with Streptokinase, urokinase should be considered in the treatment of patients who have extensive iliofemoral venous thrombosis or acute massive embolism.
  • Thrombolytic therapy has not yet been shown to reduce the mortality in patients with DVT or PE.

Pulmonary embolectomy that can only be carried out in cardiac surgery units.