1. Pulmonary Embolism & DVT

2. Introduction Pathophysiology Risk Factors Symptoms Lab Findings Radiology Findings Treatment Prevention

3. Pathophysiology Dislodgement of a blood clot: Lower Extremities: 65% to 90% Pelvic venous system Renal venous system Upper Extremity Right Heart

4. Risk Factors for PE and DVT Immobilization Surgery within the last 3 months Stroke History of venous thromboembolism Malignancy Preexisting respiratory disease Chronic Heart Disease Age >60 Surgery requiring >30mins of anesthesia Recent travel (past 2weeks, >4 hours) Varicose veins Superficial vein thrombosis Central VV catheter/port/pacemaker Additional RF in Women: Obesity BMI >/=29 Heavy smoking (>25cigs/day) Hypertension Pregnancy

5. Well’s Criteria Clinical Signs and Symptoms of DVT? (Calf tenderness, swelling >3cm, errythema, pitting edema affected leg only) +3 PE Is #1 Diagnosis, or Equally Likely+3 Heart Rate > 100+1.5 Immobilization at least 3 days, or Surgery in the Previous 4 weeks +1.5 Previous, objectively diagnosed PE or DVT?+1.5 Hemoptysis+1 Malignancy w/ Rx within 6 mo, or palliative?+1 >6: High Risk 2 to 6:Moderate Risk 2 or less:Low Adapted with permission from Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED d-dimer. Thromb Haemost 2000;83:416-20.

6. P.E. and Malignancy A Presenting sign in: –Pancreatic cancer –Prostate cancer Late sign in: –Breast cancer –Lung cancer –Uterine cancer –Brain cancer

7. Symptoms of P.E. Dyspnea Pleuritic pain Cough Hemoptysis (blood tinged/streaked/ pure blood)

8. Signs of P.E. Tachypnea Rales Tachycardia Hypoxia S4 Accentuated pulmonic component of S2 Fever: T <102 F

9. Signs in Massive P.E. “Massive PE”: hemodynamic instability with SBP /=40mmHg Signs as before PLUS: –Acute right heart failure Elevated J.V.P. Right-sided S3 Parasternal lift

10. P.E. & Leg Symptoms Most patients with P.E. do not have leg symptoms at time of diagnosis Patients with leg symptoms may have asymptomatic P.E.

11. Lab & Radiologic Findings in P.E. ABG BNP Cardiac Enzymes: Troponin D-dimer EKG CXR Ultrasound V/Q Scan Angiography

12. Lab Findings in P.E. (ABG) ABG: –Hypoxemia –Hypocapnia (low CO2) –Respiratory Alkalosis –Massive PE: hypercapnia, mix resp and metabolic acidosis (inc lactic acid) –Patients with RA pulse ox readings <95% are at increased risk of in-hospital complications, resp failure, cardiogenic shock, death

13. Lab Findings in P.E. (BNP) BNP (beta natruretic peptide) –Insensitive test –Patient’s with PE have higher levels than pts without, but not ALL patients with PE have high BNP –Good prognostic value measure: if BNP >90 associated with adverse clinical outcomes (death, CPR, mechanical vent, pressure support, thrombolysis, embolectomy)

14. Lab Findings in P.E. (Troponin) Troponin –High in 30-50% of pts with mod to large PE –Prognostic value if combined pro-NT BNP Trop I >0.07 + NT-proBNP >600 = high 40 day mortality

15. Lab Findings in P.E. (D-dimer) D-dimer: –Degredation product of fibrin –>500 is abnormal –Sensitivity: High, 95% of PE pts will be positive –Specificity: Low –Negative Predictive Value: Excellent

17. S1Q3T3!!!

18. RAD Right Atrial Enlargement

19. Lab Findings in P.E. (cont’d) EKG –2 Most Common finding on EKG: Nonspecific ST-segment and T-wave changes Sinus Tachycardia –Historical abnormality suggestive of PE S1Q3T3 Right ventricular strain New incomplete RBBB

20. Radiologic Findings in P.E.

21. GOLD STANDARD IN DIAGNOSING PULMONARY EMBOLISM? PULMONARY ANGIOGRAM

22. Radiology Findings in P.E. (cont’d) CXR: –Normal –Atelectasis and/or pulmonary parenchymal abnormality –Pleural Effusion –Cardiomegally

23. What’s This??? Hampton’s Hump

24. How About This??? Westermark's Sign: an abrupt tapering of a vessel caused by pulmonary thromboembolic obstruction. This CXR shows enlargement of the left hilum accompanied by left lung hyperlucency, indicating oligemia (Westermark's sign).

25. Radiology Findings in P.E. (cont’d) V/Q Scan: Results: High, Intermediate, Low Probability Best if combined with Clinical Probability (PIOPED study): –High Clinical Prob + High Prob VQ= 95% likelihood of having a P.E. –Low Clinical Prob + Low Prob VQ= 4% likelihood of having a P.E.

26. Radiology Findings in P.E. (cont’d) Lower Extremity Ultrasounds If DVT found then treatment is same if patient has a P.E. Disadvantage: –If negative, patients with PE may be missed –If false positive (3%), unnecessary intervention

27. Radiology Findings in P.E. (cont’d) CT Pulmonary Angiography (CT-PA) Widely used Institution dependent Sensitivity (83%) Specificity (96%): if negative, very low likelihood that pt has P.E.

28. Radiology Findings in P.E. (cont’d) Pulmonary Angiogram Gold Standard Not easily accessible Radiologist dependent

29. Radiology Findings in P.E. (cont’d) Echocardiogram Increased Right Ventricle Size Decreased Right Ventricular Function Tricuspid Regurgitation Rarely: RV thrombus Regional wall motion abnormalities that spare the right ventricle apex (McConnell’s Sign)

30. Hypercoagulability Work Up No consensus on who to test Increased likelihood if: –Age <50y/o without immediate identifiable risk factors (idiopathic or provoked) –Family history –Recurrent clots –If clot is in an unusual site (portal, hepatic, mesenteric, cerebral) –Unprovoked upper extremity clot (no catheter, no surgeries) –Patient’s with warfarin induced skin necrosis (they may have protein C deficiency

31. Hypercoagulability Work Up –Protein C/S deficiency –Factor V leiden deficiency –AntiThrombin III deficiency –Prothrombin 20210 mutation –Antiphospholipid antibody –High Homocysteine

32. Most Common Cause of Congenital Hypercoagulablity Protein C resistance d/t Factor V leiden mutation

33. Treatment of P.E. Respiratory Support: Oxygen, intubation Hemodynamic Support: IVF, vasopressors Anticoagulation Thrombolysis IVC Filter

34. Anticoagulation Start during resuscitation phase itself If suspicion high, start emperic anticoagulation Evaluate patient for absolute contraindication (i.e.: active bleeding)

35. Anticoagulation (cont’d) HEPARIN: –Lovenox: if hemodynamically stable, no renal function 1mg/kg BID OR 1.5mg/kg QDay –Heparin gtt: if hypotension, renal failure 80units/kg bolus then 18units/kg infusion Goal PTT1.5 to 2.5 times the upper limit of normal COUMADIN: –Start once acute anticoagulation achieved –Start with 5mg PO qday OR 10mg PO q day –If start with 10mg then achieve therapeutic INR 1.4 days sooner –Complications and morbidity no different in 5mg or 10mg start –Goal INR 2 to 3

38. Duration of Anticoagulation for DVT or PE* EventDurationStrength of Recommendation First Time event of Reversible cause (surgery/trauma) At least 3 mosA First episode of idiopathic VTE At least 6 mosA Recurrent idiopathic VTE or continuing risk factor (e.g., thrombophilia, cancer) At least 12 mosB Symptomatic isolated calf-vein thrombosis 6 to 12 weeksA *From American College of Chest Physicians

39. Thrombolysis Considered once P.E. diagnosed If chosen, hold anticoagulation during thrombolysis infusion, then resumed Associated with higher incidence of major hemorrhage Indications: persistent hypotension, severe hypoxemia, large perfusion defecs, right ventricular dysfunction, free floating right ventricular thrombus, paten foramen ovale Activase or streptokinase

40. IVC Filter Indication: –Absolute contraindication to anticoagulation (i.e. active bleeding) –Recurrent PE during adequate anticoagulation –Complication of anticoagulation (severe bleeding) Also: –Pts with poor cardiopulmonary reserve –Recurrent P.E. will be fatal –Patient’s who have had embolectomy –Prophylaxis against P.E. in select patients (malignancy)

41. Embolectomy Surgical or catheter Indication: –Those who present severe enough to warrant thrombolysis –In those where thrombolysis is contraindicated or fails

43. Questions?