{"id":5581,"date":"2011-04-09T08:47:47","date_gmt":"2011-04-09T12:47:47","guid":{"rendered":"http:\/\/insidesurgery.com\/?p=5581"},"modified":"2011-04-12T20:00:47","modified_gmt":"2011-04-13T00:00:47","slug":"pulmonary-embolism-pe","status":"publish","type":"post","link":"https:\/\/insidesurgery.com\/2011\/04\/pulmonary-embolism-pe\/","title":{"rendered":"Pulmonary Embolism (PE)"},"content":{"rendered":"


\nPathophysiology<\/strong><\/p>\n

1)<\/strong> migration of thrombus or other materials to pulmonary arterial vasculature 2)<\/strong> most common cause is venous thrombus – from “deep veins” of iliac, femoral, and pelvic systems 3)<\/strong> factors that contribute to arterial and venous thrombus formation classically described as Virchow’s triad – stasis of blood, vessel wall injury, hypercoagulable state 4)<\/strong> generally – big embolism, big complications.<\/p>\n

Signs and Symptoms<\/strong><\/p>\n

1)<\/strong> tachypnea 2)<\/strong> dyspnea 3)<\/strong> chest pain 4)<\/strong> tachycardia 5)<\/strong> systemic hypotension 6)<\/strong> hemoptysis 7)<\/strong> cyanosis 8)<\/strong> chest splinting 9)<\/strong> friction rub 10)<\/strong> new heart gallop<\/p>\n

Characteristic Test Findings<\/strong><\/p>\n

EKG<\/em> – 1)<\/strong> sinus tachycardia 2)<\/strong> right-sided heart volume overload – Q waves in lead 3, S waves in lead 1, inverted T wabes in lead 3 3)<\/strong> ST segment depression 4)<\/strong> atrial fibrillation Echocardiogram<\/em> – 5)<\/strong> right ventricle overload 6)<\/strong> tricuspid regurgitation Nuclear medicine<\/em> – 7)<\/strong> mismatch on xenon ventilation\/technetium perfusion scan Laboratory<\/em> – 8)<\/strong> presence of lupus anticoagulant 9)<\/strong> deficiency of activated protein C\/protein S\/antithrombin 3 Radiology<\/em> – 10)<\/strong> deep venous thrombus on Doppler ultrasound 11)<\/strong> mass defect on pulmonary arteriogram\/spiral CT 12)<\/strong> Westermark’s sgin (loss of lung vasculature markings at site of emboli) and Hampton’s hump on chest radiograph.<\/p>\n

Histology\/Gross Pathology<\/strong><\/p>\n

venous thrombus – 1)<\/strong> forms when platelets adhere to venous sinus 2)<\/strong> enlarges by successive deposition of aggregated platelets, leukocytes, and fibrin 3)<\/strong> elongates both antegrade and retrograde<\/p>\n

Associated Conditions<\/strong><\/p>\n

increased incidence with<\/em> – 1)<\/strong> pregnancy\/bedrest 2)<\/strong> postoperatively 3)<\/strong> hip and femur fractures 4)<\/strong> atrial fibrillation 5)<\/strong> post-MI 6)<\/strong> cancer (especially prostate and pancreas) 7)<\/strong> oral contraceptives (especially in smokers) 8)<\/strong> spinal cord injury 9)<\/strong> emphysema 10)<\/strong> sytemic infection 11)<\/strong> renal cell carcinoma (50% risk) 12)<\/strong> tumors in right heart<\/p>\n

Incidence\/Epidemiology<\/strong><\/p>\n

1)<\/strong> 600,000 cases\/200,000 deaths yearly in USA 2)<\/strong> 64% of patient over age of 40 have subclinical PE in lungs at autopsy 3)<\/strong> more common in right lung and lower lobes 4)<\/strong> most common in middle to old age<\/p>\n

Treatment<\/strong><\/p>\n

1)<\/strong> best treatment is prevention 2)<\/strong> low molecular weight or unfractionated heparin 3)<\/strong> pneumatic compression devices on legs (must be placed pre-op and data are mixed on whether they work on the arms 4)<\/strong> early mobilization After PE diagnosis<\/em> – 5)<\/strong> infusion of unfractionated heparin or administration of low-molecular weight heparin followed by 3-6 months of warfarin or continued low-molecular weight heparin shots 6)<\/strong> surgical removal if life-threatening via modified Trendelenburg procedure 7)<\/strong> tPA, if life-threatening is also an option 8)<\/strong> caval interruption (e.g., Greenfield’s filter), if anticoagulation post-PE is not possible or PE is recurrent while patient is on anticoagulation.<\/p>\n

Tips for USMLE<\/strong><\/p>\n

1)<\/strong> paradoxical embolus is embolus that moves from venous system to arterial system via intracardiac defect (most commonly patent foramen ovale, atrial septal defect, and ventricular septal defect) 2)<\/strong> most common EKG finding is sinus tachycardia 3)<\/strong> if question mentions “S1-Q3-T3” pattern on EKG, think PE 4)<\/strong> chronic PE, as opposed to the acute PE described above, are recurrent PE that manifest as pulmonary hypertension leading to pulmonary and heart failure
\n<\/p>\n","protected":false},"excerpt":{"rendered":"

Pathophysiology 1) migration of thrombus or other materials to pulmonary arterial vasculature 2) most common cause is venous thrombus – from “deep veins” of iliac, femoral, and pelvic systems 3) factors that contribute to arterial and venous thrombus formation classically described as Virchow’s triad – stasis of blood, vessel wall injury, hypercoagulable state 4) generally […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_exactmetrics_skip_tracking":false,"_exactmetrics_sitenote_active":false,"_exactmetrics_sitenote_note":"","_exactmetrics_sitenote_category":0,"_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","footnotes":""},"categories":[63],"tags":[4296,4308,4298,4307,4295,4297,4306],"yoast_head":"\nPulmonary Embolism (PE) - 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