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Pulmonary Embolism - Kaczmarek - VA NR 8.5.19

Dr. Kaczmarek presents a case of 62 YO Male with no PMH who presented with hyperacute SOB and was found to have Acute Hypoxic Respiratory Failure. He was diagnosed with an accute unprovoked, sub-massive Pulmonary Embolism (PE).


PE Def'n: Obstruction of the pulmonary artery or one its branches by material, e.g. thrombus, air, fat, tumor from somewhere in the body - most commonly thrombus that has embolized from the lower extremities


Epi: roughly 1 in 1,000 incidence, men with slightly higher predilection.


Pathophys (thromboembolism):

Virchow's triad: venous stasis, endothelial injury, hypercoagulable state

Source of thrombus:

majority LE (deep veins: iliac, femoral, popliteal)

Superficial LE VTs are 1/2 as likely to embolize

Presentation (sensitivities):

Sxs: Dyspnea at rest or with exertion (73%), Pleuritic pain (66%), Calf/thigh pain or swelling (44%), Cough (37%), Orthopnea (28%), Wheezing (21%), Hemoptysis (13%), Arrhythmia (Afib), presyncope, syncope, hemodynamic collapse (<10%)


PE findings: Tachypnea (54%), Calf/thigh pain, swelling, edema (47%), Tachycardia (24%), Rales (18%), Accentuated pulmonic component of 2nd heart sound (15%), JVD (14%)


Dx: Gold standard CT-PE. V/Q scan if CI to CT and no evidence of V/Q mismatch on CXR.


Criteria:


Modified Wells:

(<2 - no further testing, 2-6 obtain D Dimer, >6 go straight to CT- PE)

PERC: if all negative, no further testing indicated! (for young patients)



Rx: based on severity (All receive supp O2 and anti-coagulation if no contraindications)

Massive: (HD instability (SBP <90 for >15min), hypotension requiring vasopressors, evidence of shock

- if no contraindications, use thrombolysis (tPa), then anti-coagulation 24+ hours after TPA administration.

- If contraindications to systemic thrombolysis, procedure is indicated (catheter directed TPA vs thrombectomy)

- vasopressors if in shock and not fluid-responsive


Sub-massive: evidence of right heart strain

- Evidence largely not supportive of TPA/procedure. Anti-coagulation and O2 Only.


Low risk - neither of above

- anti-coagulation and O2 only



IVC Filters: rarely used. Consider in pts with high risk for re-embolization with contraindications for anticoagulation.


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