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[medicinethought-blog]

PE

PE

PE is a blockage of an artery in the lungs by a substance that has traveled through the bloodstream (embolism). PE usually results from a blood clot in the leg that travels to the lung.The risk of blood clots is increased by cancer, prolonged bed rest, smoking, stroke, certain genetic conditions, pregnancy, obesity, and after some types of surgery. And can sometimes be due to the embolization of air, fat, or amniotic fluid.

Symptoms

Syspnea (shortness of breath)

Tachypnea (rapid breathing),

Chest pain

Cough

Hemoptysis (coughing up blood).

Cyanosis (blue discoloration, usually of the lips and fingers),

Collapse,

Circulatory instability because of decreased blood flow through the lungs and into the heart

Sudden death

A pleural friction rub

A pleural effusion

Strain on the right ventricle

A fever

Risk factors

Alterations in blood flow due to injury, pregnancy,obesity cancer

Factors in the vessel wall due to surgery, endothelial injury

Factors affecting the properties of the blood due to estrogen-containing hormonal contraception

Cancer

Diagnosis

CT pulmonary angiography (CTPA) is a pulmonary angiogram obtained using CT with radiocontrast. its non-invasive, its larger accessibility, and you can identify other lung disorders from the differential diagnosis in case there is no pulmonary embolism. Assessing the accuracy of CT pulmonary angiography is lowered by the rapid changes in the number of rows of detectors available in multidetector CT (MDCT). CTPA is not inferior to VQ scanning, and identifies more.

A VQ shows that some areas of the lung are being ventilated but not supplied with blood, this type of examination is as accurate as CT, but is less used. It is particularly useful in people who have an allergy to iodinated contrast, impaired renal function, or are pregnant. The test can be performed with two-dimensional imaging, or single photon emission tomography (SPECT) which enables three-dimensional imaging. Hybrid devices combining SPECT and CT (SPECT/CT) further enables identification of abnormalities.

Low chance of PE, a normal D-dimer level (blood test) is enough to portray presence of PE, D-dimer is highly sensitive (positive implies patient doesn’t have PE and visa versa). Full blood count is done, clotting status (PT, aPTT, TT), and some screening tests (erythrocyte sedimentation rate, renal function, liver enzymes, electrolytes).

Treatment

Anticoagulant Therapy

Anticoagulant therapy is the mainstay of treatment. Heparin or fondaparinux are given, while warfarin, acenocoumarol, or phenprocoumon therapy also starts within hospital. Low molecular weight heparin may reduce bleeding among people with pulmonary embolism. Warfarin therapy often requires an often adjustment and monitoring to dosage for up to 6 months. In cancer patients LMWH (low molecular weight heparin) is favored over warfarin and it is continued for six months and pregnant women are often placed on LMWH until at least six weeks after birth to avoid the teratogenic effects of warfarin. (Distort fetus)

Thrombolysis

PE causing hemodynamic instability (low blood pressure) is an indication for thrombolysis (the destruction of the clot with medication). Catheter-directed thrombolysis (CDT) is a new technique found to be relatively safe and effective for massive PEs. This involves accessing the venous system by placing a catheter into a vein in the groin and guiding it through the veins by using fluoroscopic imaging until it is located next to the PE in the plunomary circulation. Medication that breaks up blood clots is released through the catheter.

Inferior vena cava filter

An inferior vena cava filter is constructed if the person has undergone surgery (therefore, anticogulant therapy is contradicted), or a person has a pulmonary embolus after being anticoagulated. It may be implanted to prevent new or existing Deep vein thrombosis from entering the pulmonary artery and combining with an existing blockage. Inferior vena cava filters should be removed when starting anticoagulation.

(An ECG with someone with pulmonary embolism)

References

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“What Are the Signs and Symptoms of Pulmonary Embolism?”. NHLBI. July 1, 2011.

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