Acute Pulmonary Embolism
Acute Pulmonary Embolism
Acute Pulmonary Embolism
When a vessel in the body in constricted by any substance, a part of this substance
called embolus, migrates in a pulmonary artery. This creates a blockage that limits
any exchange between the blood and lung. This condition is called an embolism.
A part of thrombus (blood clot) present in the deep veins, most commonly lower
limbs, breaks off and travels to a pulmonary artery.
2.Acquired causes
a.increase in procoagulant enzymes
-Estrogen increased (from pregnancy or OCP medication)
-Lung cancers/pancreatic cancers are associated increase of procoagulant activity
-gas embolism: bubble forming in pulmonary artery, common in scuba diving due to
the sudden change of pressure of the water
-fat embolism: in long bones fracture, fat globules within the medullary cavity of the
bone can enter the circulation and create a pulmonary embolism
-amniotic embolism: leak of amniotic fluid in pregnant women, some of the proteins
acts as embolus
-sceptic embolism: common in IV dugs abuser, tricuspid valve site of vegetation
Pathophysiology
Embolus comes from deep vein of lower limb, passes through inferior or superior
veina cava, it arrives at right atrium and passes to the right ventricle. From the
right ventricle it goes to the pulmonary trunk.
Ventilation/perfusion
In alveoli, ventilation is normal but perfusion is low.
O2 level is decreased leading to hypoxemia
➔ Hypoxemia -> Dyspnea
➔ tachypnea
➔ decrease CO2 level -> V/q mismatch
➔ PH increase
➔ respiratory alkalosis
clinical features
-tachypnea/dyspnea
-tachycardia
-chest pain
-hypotension
-signs of DVT:
-asymmetric swollen and redness (eg. edema)
-pain in leg
-hard/sore veins
Diagnosis
Well’s score
If PE unlikely
Do D-Dimer assay
➔ positive -> do CT
➔ negative -> no PE
if PE likely
do CT
➔ positive -> PE confirmed
➔ negative -> no PE
➔ unsure -> DO FURTHER TESTS
D-dimer assay : D-Dimer is a small protein present in blood after blood clot is
degraded. The test is used for PE diagnosis
Chest x-ray
➔ usually normal
➔ common findings
o enlarged pulmonary artery
o wedge opacity
o elevated diaphragm
o pleural effusion
EKG
➔ used to exclude MI and pericarditis
➔ usually normal
➔ common findings include
o Sinus tachycardia
o Right ventricular strain om V1-V4 (inversion of T-wave)
o S1Q3T3 on lead 1 and lead 3 (lead 1 deep 5 wave, lead 3 deep Q and
T wave)
Treatment
If patient has submassive PE (hemodynamically stable)
➔ Anticoagulant
If contraindicated.
▪ do Inferior vena cava filter
Medications
Anticoagulants (prevent blood clot formation)
➔ Heparin
o Unfractionated heparin
▪ IV
▪ APTT monitored
▪ Hospitalized
➔ Warfarin
o Warfarin K antagonist
o Taken orally
o Needs 5 days to begin
o INR monitored
➔ Thrombolytics
o Breaks down blood clots
o Has a risk of second hemorrhage
o Used on massive PE patients