Pe 2
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This document summarizes pulmonary embolism (PE), including epidemiology, symptoms, diagnostic criteria like the Wells criteria and PERC rule, diagnostic tests like CT pulmonary angiography and V/Q scan, treatment with anticoagulation and thrombolytics, and classifications of massive versus submassive PE.
![CT pulmonary Angiography Sensitivity/Specificity ~90% CTPA use increased 10-fold from 1998-2006 Incidence increased 81% from 1998-2006 (112/100,000) with only 3% mortality reduction Increased in-hospital antigcoagulation complications during that same time period Wiener RS et al. Time trends in pulmonary embolism in the United States: Evidence of overdiagnosis. Arch Intern Med 2011 May 9; 171:831. Tapson VF. Acute pulmonary embolism: Underdiagnosed and overdiagnosed. [invited commentary] Arch Intern Med 2011 May 9; 171:837.](https://image.slidesharecdn.com/pe2-110725134344-phpapp02/85/Pe-2-14-320.jpg)
Pe 2
- 1. Pulmonary Embolism Kevin Jones PGY-3, Emergency Medicine Arrowhead Regional Medical Center July 20, 2011
- 2. Epidemiology 2 nd leading cause of sudden, unexpected, nontraumatic death 650-900,000 PE’s diagnosed each year ~200,000 deaths/years due to PE 50% of patients with DVT have perfusion defects on nuclear imaging 40% of patients with PE have asymptomatic DVT
- 3. Symptoms Symptoms Dyspnea Chest pain Others: syncope, seizure-like activity Signs Tachycardia Tachypnea Hypoxia
- 6. Wells Criteria Clinical signs of DVT Recent sx or immobilization HR >100 bpm Previous h/o PE or DVT Hemoptysis Malignancy PE most likely diagnosis Points 3 1.5 1.5 1.5 1 1 3 Wells PS, Ginsberg JS, Anderson DR, et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med. 1998;129:997-1005.
- 7. Simplified Revised Geneva Score Age >65 Previous history of PE or DVT Sx or Fx within 1 month Active malignancy HR 75-94 HR >95 Unilateral leg edema Unilateral leg pain Hemoptysis Points 1 1 1 1 1 2 1 1 1 Risk factors Clinical signs Symptoms Wicki J, Perneger TV, Junod AF, et al. Assessing clinical probability of pulmonary embolism in the emergency ward. Arch Intern Med. 2001;161:92-97.
- 9. PERC Age < 50 HR < 100 SpO2 > 94% No unilateral leg swelling No hemoptysis No recent surgery (<4 weeks) No prior PE/DVT No oral hormone use Kline JA, Mitchell AM, Kabrhel C, et al. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost. 2004;2:1247-1255.
- 11. D-dimer Elevated in several disease processes… Different assays have different sensitivities PE in low-risk patients with a negative D-dimer… Thrombus formation >72 hrs before blood draw (circulating dimer t 1/2 = 8 hrs) Subsegmental PE
- 12. D-dimer Assays Latex-agglutination assay Readily available Quick & easy to perform Less expensive Sensitivity ~80% NPV 91% ELISA assay Technician dependent Takes longer More expensive Sensitivity ~95% NPV 99.5% Stein P et al. D-dimer for the Exclusion of Deep Venous Thrombosis and Pulmonary Embolism: A Systematic Review . Ann Intern Med 2004;140:589-602.
- 13. Diagnosis CT Pulmonary Angiography V/Q scan Direct Pulmonary Angiography Lower extremity U/S Sensitivity for PE <40% Consider in renal insufficiency, contrast allergy, pregnant
- 14. CT pulmonary Angiography Sensitivity/Specificity ~90% CTPA use increased 10-fold from 1998-2006 Incidence increased 81% from 1998-2006 (112/100,000) with only 3% mortality reduction Increased in-hospital antigcoagulation complications during that same time period Wiener RS et al. Time trends in pulmonary embolism in the United States: Evidence of overdiagnosis. Arch Intern Med 2011 May 9; 171:831. Tapson VF. Acute pulmonary embolism: Underdiagnosed and overdiagnosed. [invited commentary] Arch Intern Med 2011 May 9; 171:837.
- 15. Massive vs. Submassive PE Massive PE = Acute PE with… Hypotension ( any single SBP <90) Pulselessness Bradycardia (HR <40) + shock Submassive PE = Acute PE without hypotension but signs of RV dysfunction/myocardial necrosis
- 17. Treatment Anticoagulation Heparin – 80mg/kg IV bolus, then 18mg/kg/hr Lovenox – 1mg/kg SC q12h Arixtra – 5-10mg SC daily Thrombolytics Alteplase
- 18. Thrombolytics Evidence of circulatory/respiratory insufficiency Hypotension (SBP <90) Hypoxia (SpO2 <95%) Evidence of RV dysfunction RV dilation/hypokinesis Elevated troponin-I (>0.4) or proBNP (>900) EKG changes FDA-recommended dose: Alteplase 100mg over 2hrs
- 20. Fibrinolysis Contraindications Relative Age > 75 Current anticoagulation use Pregnancy Noncompressible vascular punctures Traumatic or prolonged CPR >10 min Recent surgery/bleeding w/in 2-4 wks Poorly controlled HTN >180/110 Dementia Recent Ischemic CVA > 3 months Absolute Prior ICH Known intracranial CV disease (AVM) Malignant intracranial neoplasm CVA within 3 months Suspected aortic dissection Active bleeding Recent surgery of spinal cord/brain Recent closed-head trauma with brain injury
- 21. Interventional Options Catheter embolectomy Surgical embolectomy Reasonable for… Massive PE if still unstable after fibrinolysis Massive/Submassive PE if fibrinolysis is contra-indicated or there is evidence of adverse prognosis
- 22. No imaging? Aggressive early management if… High clinical pre-test probability RV dysfunction Sustained hypotension (SBP <90 for >15 min or requiring inotropic support, & not clearly due to another cause)
- 23. Documentation Pearls Why patient is not high risk for MI, UA, Dissection, PE No Risk Factors No recent surgeries No clinical signs of DVT Negative D-dimer or PERC
Editor's Notes
- #4: Symptoms occur with at least 20-30% occlusion of vasculature
- #7: Gestalt based on clinician’s training, experience, and judgement PIOPED study (Prospective Investigation Of Pulmonary Embolism Diagnosis) was first to study gestalt in diagnosis (JAMA 1990) Low risk 0-19%, Intermediate 20-79%, high 80-100% PE Dx 9%, 30%, 70%
- #8: 0-2 = PE unlikely 3-7 = PE likely
- #10: If patient is low-risk by gestalt (<15% chance of PE within next month) & PERC negative, there is <2% chance of clinically diagnosed VTE PERC provides one set of criteria to rule out PE (ACEP Level B recommendation)
- #12: False-positives = age >70, pregnancy, active malignancy, recent surgery, liver disease, RA, infections, trauma False-negatives = Coumadin use, symptoms >5days, small clots or infarction, isolated calf vein thrombosis
- #13: ACEP Level A – low pre-test probablity + negative dimer (ELISA, turbidometric) can rule out PE Level C – intermediate pre-test probablity + negative dimer MAY be used to rule out PE
- #15: Patient needs 20 ga peripheral IV or larger Radiation = 10-20 mSv (increases risk of CA to 1:500 lifetime risk) ACEP Level B – low risk or PE unlikely (Wells <4), CTPA can exclude PE Level C – intermediate risk (consider additional testing); high risk (must do additional testing)
- #19: BNP is one marker that gives a good view of how the patient will look in 6 months (BNP <900 is good) Thrombolysis is only useful for those who are at high risk for dying from PE More study needs to be done for thrombolysis in normotensive patients with RV dysfunction/elevated troponin Currently PEITHO study (PE Thrombolysis Study) Peitho = goddess of persuasion, charming speech, & seduction (study is sponsored by manufacturer of the lytic agent used)