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Pulmonary embolism: Difference between revisions
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<section begin="radiology" />'''Pulmonary embolism''' (PE) is a form of [[venous thromboembolism]] and is a serious complication of [[deep vein thrombosis]] which can lead to death in 30 – 60% of cases, and is more common in case of proximal DVT. | <section begin="A&IC" /><section begin="radiology" />'''Pulmonary embolism''' (PE) is a form of [[venous thromboembolism]] and is a serious complication of [[deep vein thrombosis]] which can lead to death in 30 – 60% of cases, and is more common in case of proximal DVT. | ||
PE is classified into three different types: | PE is classified into three different types: | ||
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* Massive PE | * Massive PE | ||
''Massive'' pulmonary embolism refers to PE which causes obstructive shock and haemodynamic instability, usually because of a saddle-thrombus (thrombus at the pulmonary trunk bifurcation). Submassive PE causes RV dysfunction but not haemodynamical instability. Nonmassive PE causes neither. | ''Massive'' pulmonary embolism refers to PE which causes obstructive [[shock]] and haemodynamic instability, usually because of a saddle-thrombus (thrombus at the pulmonary trunk bifurcation). Submassive PE causes RV dysfunction but not haemodynamical instability. Nonmassive PE causes neither. | ||
== Risk factors == | |||
* Hereditary pro-coagulant mutation (Leiden, AT III def, etc.) | |||
* Immobility | |||
* Post-surgery | |||
* Smoking | |||
* Obesity | |||
== Clinical features == | == Clinical features == | ||
Pulmonary embolism has no specific symptoms and can be difficult to recognise clinically. Symptoms occur acutely. The most common symptoms include dyspnoea, pleuritic chest pain, dizziness, and cough. Other possible symptoms include tachypnoea, haemoptysis, and jugular vein distension. Symptoms of DVT may be present. Massive PE gives syncope or haemodynamic instability. | Pulmonary embolism has no specific symptoms and can be difficult to recognise clinically. Symptoms occur acutely and are not specific for PE. The most common symptoms include dyspnoea, pleuritic chest pain, dizziness, and cough. Other possible symptoms include tachypnoea, haemoptysis, and jugular vein distension. Symptoms of DVT may be present. Massive PE gives syncope or haemodynamic instability. | ||
== Diagnosis and evaluation == | == Diagnosis and evaluation == | ||
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* [[Right bundle branch block|RBBB]] | * [[Right bundle branch block|RBBB]] | ||
[[Arterial blood gas]] may show hypocapnia and hypoxaemia. [[Troponin|Troponins]] and <abbr>[[NT-proBNP]]</abbr> may be positive due to the strain on the heart. | [[Arterial blood gas]] may show hypocapnia and hypoxaemia. [[Troponin|Troponins]] and <abbr>[[NT-proBNP]]</abbr> may be positive due to the strain on the heart.<section begin="radiology" /> | ||
<section begin="radiology" /> | |||
=== Imaging === | === Imaging === | ||
The gold standard for PE diagnosis is [[CT pulmonary angiography]] (CTPA), a rapid sequence with IV contrast where the CT scanner spirals around the patient in one breath hold. The scan itself takes only seconds, but the whole procedure including administration of contrast and set-up takes up to 10 minutes. | The gold standard for PE diagnosis is [[CT pulmonary angiography]] (CTPA), a rapid sequence with IV contrast where the CT scanner spirals around the patient in one breath hold. The scan itself takes only seconds, but the whole procedure including administration of contrast and set-up takes up to 10 minutes. | ||
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Once the patient is stabilised, definitive treatment must be initiated. Patients with massive PE should be managed with anticoagulation as well as [[thrombolysis]] or embolectomy. Thrombolysis involves administration of a [[tPA]] like alteplase via a peripheral IV catheter or directly into the pulmonary circulation to dissolve the clot. Embolectomy refers to physical removal of the clot, with a catheter or surgery. | Once the patient is stabilised, definitive treatment must be initiated. Patients with massive PE should be managed with anticoagulation as well as [[thrombolysis]] or embolectomy. Thrombolysis involves administration of a [[tPA]] like alteplase via a peripheral IV catheter or directly into the pulmonary circulation to dissolve the clot. Embolectomy refers to physical removal of the clot, with a catheter or surgery. | ||
Patients with nonmassive PE should be anticoagulated with [[LMWH]] or <abbr>[[UFH]]</abbr>, or given [[IVC filter]] is anticoagulation is contraindicated. Anticoagulation should also be initiated in patients at high suspicion for PE, even if the diagnosis isn’t made yet, as long as there are no contraindications. | Patients with nonmassive PE should be anticoagulated with [[LMWH]] or <abbr>[[UFH]]</abbr>, or given [[IVC filter]] is anticoagulation is contraindicated. Anticoagulation should also be initiated in patients at high suspicion for PE, even if the diagnosis isn’t made yet, as long as there are no contraindications.<section end="A&IC" /> | ||
After the first 5 – 10 days of anticoagulation, we may switch to oral anticoagulants, preferably [[DOAC|DOACs]]. After three months, the patient is reassessed as described for DVT. | After the first 5 – 10 days of intravenous anticoagulation, we may switch to oral anticoagulants, preferably [[DOAC|DOACs]]. After three months, the patient is reassessed as described for DVT. | ||
== Complications == | == Complications == | ||
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<noinclude>[[Category:Haematology]] | <noinclude>[[Category:Haematology]] | ||
[[Category:Internal Medicine (POTE course)]]</noinclude> | [[Category:Internal Medicine (POTE course)]] | ||
</noinclude> | |||