Pulmonary thromboembolism

PulmonaryThrombo-Embolism

It is a blockage of the pulmonary artery or its tributaries by an embolus coming from DVT in 90% of cases, while the other 10% comes from the heart

The burden of PTE

PM finding :
5% of hospital death are due to PTE
While 40-50% who die in hospital were found to have DVT.
This indicates that PTE is a common problem in hospital practice

Thromboembolism epidemiology

5 million DVT’s
900,000
PE’s
290,000 fatalities
Heit J. Blood. 2005;106:910.

Thromboembolism is a disease of hospitalized patients

Heit Mayo Clin Proc 2001; 76:1102
Goldhaber Am J Cardiol 2004; 93:259


50% in nursing homes or
<90 days post-discharge
71% received no prophylaxis
in prior 30 days

DVTClinical Features

Unilateral leg swelling & pain in the thigh & calf muscles
O / E:
The leg is swollen, tender, hot & pitting oedema is present.

Virchow’s triad

Venous Stasis
Hypercoagulable State
Endothelial Injury

Advancing age

Immobilization
Stroke - cord injury
Anesthesia
Heart or lung failure
Hyperviscosity
Surgery
Prior DVT
Venous access
Trauma
Sepsis
Vasculitis
Cancer
Estrogen
Family history
Sepsis
HIT
Protein C, S or AT III deficiency
Activated protein C resistance (Leiden)
Hyperhomocystenemia
Antiphospholipid antibody
Prothrombin 20210 mutation


Venous thromboembolism
• ~50%
• ~50%
• ~10%
• 90%
• 5-30%?
• 63-70% of fatal PE’s
• unsuspected during life
• Stein Chest 1995; 110:978
• Sandler J R Soc Med 1989; 82:203

Clinical Presentation

Clinical features of DVT
Clinical features of the type of PTE
1. MassivePTE
2. Less massive PTE
3. Pulmonary infarction
4. Recurrent small pulmonary emboli

Diagnosis

Clinical (DVT, Type, Suspect)
Radiological (CXR, PCTA, Cath)
ECG
ECHO
Radioactive scan (V/Q)
Lab. Investigation (D-dimer)


Clinical prediction rules
Factor points
Signs and symptoms of DVT 3
Alternate diagnosis less likely 3
Pulse >100 1.5
Immobilization / surgery w/i 4 wk 1.5
Previous DVT/PE 1.5
Hemoptysis 1
Malignancy 1
High > 6 (50%), Moderate 2-6 (19%), Low <2 (2%)
• Wells Ann Intern Med 1998; 129, 997

Diagnosis

Clinical (DVT, Type, Suspect)
Radiological (CXR, PCTA, Cath)
ECG
ECHO
Radioactive scan (V/Q)
Lab. Investigation (D-dimer)

Management

A. Prevention:
1. Early postoperative mobilization
2. Correct faulty posture
3. Exercise during long journey
4. treatment of dehydration & CHF
5. IVC emboli prevention
6. Prophylaxis
B. Treatment of established PTE


Treatment of established PTE