Pulmonary embolism: Difference between revisions
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==Background==
==Background==
*Suspect in pt w/ dyspnea, tachypnea, or pleuritic pain
*Only 40% of ambulatory ED pts w/ PE have concomitant DVT
*Only 40% of ambulatory ED pts w/ PE have concomitant DVT
*Hypoxemia is unpredictable
*97% of pts p/w dyspnea, tachypnea, or pleuritic pain


==Diagnosis==
==Diagnosis==
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*CTPA if GFR >60
*CTPA if GFR >60
*V/Q if GFR <60
*V/Q if GFR <60
==Work-Up==
==DDx==
==Disposition==
==See Also==
==Source==


==TREATMENT==
==TREATMENT==
*Oxygen
===Anticoagulation===
*IVF
**Give cautiously as incr. RV wall stress may lead to ischemia
*Pressors
**Nnorepi, epi, or dopa if 1L NS fails to raise BP
*Anticoagulation
**Indicated for all patients with confirmed PE or high clinical suspicion
**Indicated for all patients with confirmed PE or high clinical suspicion
**Risk-benefit: (untreated PE = 30% mortality, major bleeding <3%)
**Treatment options:
**Treatment options:
***SC LMWH - First-line agent for most hemodynamically stable patients
***LMWH SC
***IV/SC UFH - Consider only in pts with:
****1st line for most hemodynamically stable pts
****Persistent hypotension
***UFH
****Increased risk of bleeding
****Consider in pts w/:
****Recent sx/trauma
*****Persistent hypotension
****Age > 70yrs
*****Increased risk of bleeding
****Concurrent ASA use
*****Recent sx/trauma
****Renal failure  
*****Renal failure (GFR <30)
****Morbid obesity or anasarca
*****Morbid obesity or anasarca (poor sc absorption)
****Thrombolysis is being considered  
*****Thrombolysis is being considered  
****Cr clearance < 30ml/min
===Thrombolysis===
*Thrombolysis
*Associated with ICH in 3% of pts
**Consider for patients with confirmed PE and shock
*Consider for patients with confirmed PE and shock
**Can also consider, although controversial, for:  
**Can also consider, although controversial, for:  
***Severe hypoxemia
***Severe hypoxemia (SpO2<90% despite O2)
***Massive embolic burden on CT
***Massive embolic burden on CT
***RV dysfunction
***RV dysfunction
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***Surgery within the previous 10 days
***Surgery within the previous 10 days
***Plt < 100K
***Plt < 100K
***Associated with intracranial hemorrhage in 3% of patients
***Mortality benefit has never been shown
***Consider embolectomy if thrombolytics are contraindicated
*PROB DETERMINATION (BY SX)
#Atypical
##Alt diag as/more likely-->low
##Alt diag less likely
###No RF --> low
###+RF --> intrmte
#Typical
##Alt diag as/more likely
###No RF --> low
###+RF --> mod
##Alt diag less likely
###No RF --> mod
###+RF --> high
#Severe
##Alt diag as/more likely->mod
##Alt diag less likely --> high
*PROBABILITY --> W/O
#Low
##No sx DVT --> d-dimer
##Neg --> R/O
##Pos --> CT
##sx DVT --> US
###neg --> go to I.1
###pos --> R/I
#Mod/high
##no sx DVT --> spiral CT
##sx DVT --> US
###neg --> go to II.1
###pos --> R/I
===Risk Factors===
#Age >50y
#Obesity >35 (BMI)
#Pregnancy
#Malignancy
#Bed Rest (3 days or more)
#Surg (<4wk)
SEVERE (DEFINITION)
#Syncope
#BP <90 with HR >100
#Requires O2
#New onet R heart failue
TYPICAL (DEFINITION)
#(>=2 of A plus >=1 of B)
##A
###dyspnea
###pleuritic CP
###hemoptysis
###rub
###PaO2 <92%
##B
###HR >90
###low grade fever (<101)
###leg sx
###CXR c/w PE
*Does not apply to pregnant women*


==Source==
==Source==
Tintinalli


Tintinalli
UpToDate
UpToDate




[[Category:Pulm]]
[[Category:Pulm]]

Revision as of 20:40, 22 May 2011

Background

  • Suspect in pt w/ dyspnea, tachypnea, or pleuritic pain
  • Only 40% of ambulatory ED pts w/ PE have concomitant DVT

Diagnosis

  • Wells Score
  1. Symptoms of DVT - 3pts
  2. No alternative diagnosis better explains the illness - 3pts
  3. HR > 100 - 1.5 pts
  4. Immobilization within prior 4wks - 1.5pts
  5. Prior history of DVT or PE - 1.5pts
  6. Active malignancy - 1pt
  7. Hemoptysis - 1pt
  • Wells Criteria:
  1. 0-1 point: Low probability (3.4%)
  2. 2-6 points: Moderate probability (27.8%)
  3. 7-12 points: High probability (78.4%)

Low Probability

Moderate Probability

  • Obtain d-dimer

High Probability

  • Consider anticoagulation before imaging!
  • CTPA if GFR >60
  • V/Q if GFR <60

TREATMENT

Anticoagulation

    • Indicated for all patients with confirmed PE or high clinical suspicion
    • Treatment options:
      • LMWH SC
        • 1st line for most hemodynamically stable pts
      • UFH
        • Consider in pts w/:
          • Persistent hypotension
          • Increased risk of bleeding
          • Recent sx/trauma
          • Renal failure (GFR <30)
          • Morbid obesity or anasarca (poor sc absorption)
          • Thrombolysis is being considered

Thrombolysis

  • Associated with ICH in 3% of pts
  • Consider for patients with confirmed PE and shock
    • Can also consider, although controversial, for:
      • Severe hypoxemia (SpO2<90% despite O2)
      • Massive embolic burden on CT
      • RV dysfunction
      • Free-floating RA or RV thrombus
      • Patent foramen ovale
    • Absolute contraindications:
      • History of hemorrhagic stroke
      • Active intracranial neoplasm
      • Recent (<2 months) intracranial sx or trauma
      • Active or recent internal bleeding in prior 6 months
    • Relative contraindications:
      • Bleeding diathesis
      • Uncontrolled severe HTN (sys BP >200 or dia BP >110)
      • Nonhemorrhagic stroke within prior 2 months
      • Surgery within the previous 10 days
      • Plt < 100K

Source

Tintinalli

UpToDate

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