6/30/16: Pulmonary Embolism

  • Remember the risk factors for AQUIRED THROMBOPHILIA:
    • Surgery (OR 21.7)
    • Trauma (OR 12.7)
    • Hospital/SNF (OR 8.0)
    • Cancer undergoing chemotherapy (OR 6.6)
    • Others: estrogen therapy, pregnancy, obesity, smoking
  • Approximately 6% of patients with unprovoked VTEs have an undiagnosed cancer at the time of the VTE; approximately 10% will be diagnosed with cancer in the following year.
  • Use the Well’s PE Criteria for those patients whom you suspect a PE; if the score is <6 consider a D-Dimer to guide management

Wells PE

EKG findings in PE:

  • Sinus tachycardia: approximately 44% of patients
  • S1Q3T3 (acute cor pulmonale): not sensitive/specific; found in 20% of patients with PE
  • RV strain patter (TWI R precordial leads V1-V4): representative of elevated PA pressures; found in approximately 34% of patients

Indications for Thrombolytics in PE:

CLEAR INDICATIONS:

  1. Persistent hypotension / shock due to an acute PE

POSSIBLE INDICATION:

  1. Severe / Worsening RV Dysfunction
  2. Cardiopulmonary arrest due to a PE
  3. Extensive clot burden
  4. Free floating RA / ventricular thrombus
  5. Patient foramen ovale

Contraindications to thrombolytics:

  1.  Intracranial neoplasm
  2. Intracranial / spinal surgery or trauma
  3. History of hemorrhagic stroke
  4. Active bleeding
  5. Any stroke within 3 months

Classification of PE and distinction:

Massive: cardiopulmonary shock or hypotension

Submassive: RV dysfunction / elevated cardiac biomarkers

Low Risk: normal echocardiogram / negative cardiac biomarkers

 

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