1. Pulmonary
embolism
-By Dr. NEEKITA

2. DEFFINATION
OBSTRUCTION OF PULMONARY ARTERY OR ONE OF THE BRANCHES BY MATERIAL (EG., THROMBUS, TUMOR, AIR, OR FAT) THAT ORIGINATED
ELSEWHERE IN BODY.

3. Types of pulmonary embolism
Pathology
Types of pulmonary embolism
Thrombotic pulmonary embolism
Acute
pulmonary embolism
Chronic
Non thrombotic pulmonary embolism

4. Non thrombtic pulmonary embolism
Fat embolism.
Air embolism.
Amniotic fluid embolism.
Tumor embolism (HCC & RCC).

5. Thrombotic pulmonary embolism
Risk factors:
Primary hypercoagulable states
protein C deficiency
lupus anticoagulant
Postoperative
Pregnancy
Prolonged bed rest / immobility
Paraneoplastic syndrome
Pills (Oral contraceptives)

6. RISK FACTOES

7. TYPES

8. SYMPTOMS
Acute pulmonary embolism has a wide spectrum of clinical manifestations ranging from absence of symptoms to sudden death.
Most patients are asymptomatic.
Dyspnea, pleuritic chest pain, cough, wheezing, orthopnea.
Calf or thigh pain
Calf or thigh swelling
Syncope.

9. SIGNS
TACHYPNEA TACHYCARDIA CRACKLES DECREASED BREATH SOUND LOUD S2 RAISED JVP

10. DVT Non-compressible venous segment
Increased venous diameter : acute thrombus
Decreased venous diameter : chronic thrombus
Loss of phasic flow on Valsalva maneuver
Absent colour flow : if completely occlusive
Increased flow in superficial veins
Lack of flow augmentation of calf squeeze

11. LABORATORY INVESTIGATIONS
ABG -HYPOXEMIA -HYPOCAPNEA -RESPIRATORY ALKLOSIS -HYPERCAPNEA,RESPIRATORY ACIDOSIS (IF MASSIVE) -METABOLIC ACIDOSIS(IF MASSIVE) TROPONIN -ELEVATED IN MODERATE TO SEVERE PE

12. Serlogical tests D dimer (ELISA)
Sensitivity & -ve predictive value: (100%).
Specificity: (50%)
False positives:
inflammatory conditions,
pregnancy,
anemia, and
leukocytosis.

13. ECG
SINUS TACHYCARDIA NON SPECIFIC ST/T CHANGES CLASSICAL FINDINGS ARE UNCOMMON -S1Q3T3 PATTERN -NEW INCOMPLETE RBBB -RV STRAIN

14. Imaging modalities for acute pulmonary embolism.
Chest x-ray.
Ventilation perfusion lung scan:
Using Technetium-99m labeled macro aggregated albumin (MAA) for perfusion scans & Xenon-133 for ventilation scans.
Helical CT angiography and indirect CT venography.
MRA
Pulmonary angiography

15. Chest x-ray Advantages:
The main role of chest x-ray is to exclude other diseases such as pneumonia or pneumothorax that may mimic pulmonary embolism clinically.
Also chest x-ray helps in the interpretation of ventilation perfusion lung scans (PIOPED criteria).
Disadvantages:
Chest x-ray has a low sensitivity & specificity in diagnosis of acute pulmonary embolism.

16. Radiographic signs of acute pulmonary embolism
Signs with relative high specificity but low sensitivity for acute pulmonary embolism:
Decreased vascularity in the peripheral lung (Westermark sign).
Enlargement of the central pulmonary artery (Fleischner sign).
Pleural based areas of increased opacity (Hampton hump).
Hemidiaphragm elevation.
Non specific signs associated with acute pulmonary embolism that may be associated with other diseases:
Focal area of increased opacity.
Linear atelectasis.
Pleural effusion.

17. Westermark’s sign

18. Westermark sign, with hilar enlargement

19. Hampton’s hump

20. Hampton’s hump
Dome shaped pleural based opacity due to lung infarction.
Pulmonary infarct is dome shaped instead of being wedge shaped because of double blood supply with preserved bronchial arteries resulting in sparing of the expected apex of the wedge.

21. Scintigraphy (ventilation perfusion lung scan)
Advantages:
Very high sensitivity 98% (it was the imaging modality of choice in diagnosis of pulmonary embolism).
Disadvantages:
The main one was high percentage of non diagnostic intermediate probability scans.
Very low specificity 10%.

22. Scintigraphic findings for acute pulmonary embolism
Ventillation perfusion mismatch.
Ventillation scan
Perfusion scan

23. Helical CT angiography & indirect CT venography
Advantages:
More accurate than scintigraphy.
Rapid.
Non invasive.
Readily available.
Also in patients without pulmonary embolism helical CT provides an alternative diagnosis.
Disadvantages:
Various pitfalls.

24. CT findings of acute pulmonary embolism
Vascular abnormalities:
Intraluminal filling defects that forms an acute angle with the vessel wall & may be surrounded by contrast material (polo mint sign or railway sign).
Total cutoff of vascular enhancement.
Enlargement of the occluded vessel.
Ancillary findings:
Pleural based wedge shaped areas of increased attenuation with no contrast enhancement.
Linear atelectasis.

25. Partial eccentric filling defect with acute angle with the vessel wall

26. Intraluminal filling defect (polo mint sign)

27. Intraluminal filling defect (railway track sign)

28. Enlargment of the occluded vessel

31. Ancillary findings of acute pulmonary embolism (atelectatic band)

32. MRA Advantages: Disadvantages (Pitfalls and artifacts):
Patient related:
respiratory motion.
MR reconstruction related:
Gibbs artifact
Wrap around.
Amplifier over ranging.
Contrast injection related:
Transient interruption of bolus.

33. MRA findings Visualization of the intravascular filling defect.
Provide physiologic information including the regional distribution of ventilation & perfusion.

34. Pulmonary MRA
Pulmonary hypertension with dilated central pulmonary arteries and pruning of peripheral pulmonary arteries

35. Pulmonary angiography
Advantages:
The most definitive technique for diagnosis of acute pulmonary embolism.
Disadvantages:
Invasive technique with the following possible complications,
Bleeding in the groin.
Recurrent ventricular arrhythmias.
Respiratory arrest requiring ventilatory support.

36. Pulmonary angiographic findings
Primary signs:
The only primary sign of acute pulmonary embolism is filling defect.
Secondary signs:
Abrupt occlusion of pulmonary artery.
Areas of oligemia with pruning of the branching vessels.

40. MANAGMENT
ANTICOAGULATION(ACUTE) -UNFRACTIONED HEPARIN -LOW MOLECULAR WEIGHT HEPARIN -FONDAPARINUX ANTICOAGULATION(CHRONIC) -WARFARIN NEW AGENTS -DABIGATRAN -RIVAROXABAN

41. UNFRACTIONED HEPARIN
PROVEN TO WORK SINCE INTRAVENOUS -BOLUS OF 80 u/kg FOLLOWED BY INFUSION AT 18 u/kg/hr. -TITRATE TO TARGET PTT * CONTROL SUBCUTANEOUS -AFTER IV BOLUSOF 5000U, 250u/kg BD -SUBCUTANEOUS BOLUS 333u/kg -APTT NOT MENTIONED.

42. LMW HEPARIN
ADMINISTERED SUBCUTANEOUSLY. EXAMPLES INCLUDE -ENOXAPARIN->BD OR OD DAILY DOSING. -DALTEPARIN ONCE DAILY. -NADROPARIN BD DOSING -TINZAPARIN DO NOT REQUIRE MONITORING IN MOST CASES.

43. FONDAPARINUX -SIMILAR OUTCOMES WHEN COMPARED TO IV UFH.
-SUBCUTANEUSLY ADMINISTRATION.
-SIMILAR OUTCOMES WHEN COMPARED TO IV UFH.
-CONTRAINDICATED IN PATIENTS WITH SEVERE RENAL FAILURE.

44. WARFARIN -ADJUSTED DOSE TO INR 2.0-3.0
-STARTED AFTER ADMINISTRATION OF HEPARIN .
-ADJUSTED DOSE TO INR

45. DURATION OF ANTICOAGULANT
FIRST EPISODE -REVERSIBLE-> 3 MONTHS -UNPROVOKED-> INDEFINITE RECURRENT PE -INDEFINITE IF RISK OF BLEEDING ACCEPTABLE.

46. NEW ANTICOAGULANTS RIVAROXABAN -FACTOR 10 A INHIBITOR.
-FDA APPROVED FOR NON VALVULAR A FIB
-POST OP THROMBOPROPHYLAXIS HIP AND KNEE REPLACEME.
-TREATMENT OF DVT
GIVEN AS 15 mg PO DOSE BD FOR 3 WEEKS THEN 20 mg DAILY

47. DABIGATRAN: ORAL THROMBIN INHIBITOR.
FDA APPROVED FOR NON VALVULAR ATRIAL FIBRILLATION.
NON INFERIOR TO WARFARIN.
GOOD SAFTY PROFILE.

48. THROMBOLYSIS
-INDICATIONS: MASSIVE PE(SBP<90 FOR >15 MIN) SEVERE HYPOXEMIA LARGE THROMBUS BURDEN RV DYSFUNCTION RV THROMBUS IS TRANSIENT SADDLE EMBOLUS

49. -INTRACRANIAL NEOPLASM
CONTRAINDICATIONS:
ABSOLUTE
-INTRACRANIAL NEOPLASM
-RECENT <3 MONTHS INTRACRANIAL SURGERY OR TRAUMA
-RECENT ISCHEMIC STROKE
-H/0 HAEMORRHAGIC STROKE
-ACUTE OR RECENT BLEEDING
RELATIVE
-BP>180 SYSTOLIC
-H/O ISCHEMIC STROKE
-RECENT INTERNAL BLEEDING
-THROMBICYTOPENIA

50. THROMBOLYTIC AGENTS
1 .TISSUE PLASMINOGEN ACTIVATOR- Tpa -ALTEPLASE -IV DRIP 100 MG OVER 2 HOURS 2 .STREPTOKINASE -IV DRIP UNITS OVER 30 MINUTES. -FOLLOWED BY U/HR FOR 24 HOURS 3 . UROKINASE SIDE EFFECTES: -BLEEDING -ALLERGIC REACTION -HYPOTENSION .

51. SURGICAL EMBOLECTOMY
-EXPERIENCED SURGEON -REQUIRES CARDIOPULMONARY BYPASS. -INDICATED AS AN ALTERNATIVE TO THROMBOLYSIS OR WHEN THROMBOLYSIS IS CONTRAINDIACATED

52. INFERIOR VENA CAVA FILTER
-’FILTER OUT’ LARGE EMBOLI FROM THE PELVIS , LOWER EXTERMITIES. -INSERTED PERCUTANEOUSLY. -INDICATED FOR PATIENTS WHO HAVE CONTRAINDICATIONS TO ANTICOAGULATION.

53. THANK YOU