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PULMONARY EMBOLIS

Dairion Gatot, Savita Handayani

Hematology -Onkology Medic Division


Internal Departement of Medical Faculty of North
Sumatera University/Haji Adam Malik General
Hospital,
Medan 2013
DIAGNOSTIC APPROACH

RECOGNITION OF RISK
FACTORS

SUSPICIOUS CLINICAL SIGNS AND SYMPTOMS

CONFIRMATION
Model for Determining the Clinical Probability of Pulmonary Embolism, According to the Wells
Score

Stein P et al. N Engl J Med 2006;354:2317-2327


MODES OF PRESENTATION

MILD SEVERE

Fever RV Dysfunction Cardiac arrest


Cough JVP high Pulseless electrical
Haemoptysis P2 > A2 activity
Pleural pain Tricuspid insuff
Tachycardia Hypoxemia
Tachypnea EKG signs
Echo signs
Differential Diagnosis of Pulmonary Embolism

Goldhaber S. N Engl J Med 1998;339:93-104


PULSELESS ELECTRICAL ACTIVITY

Any semiorganized electrical activity seen on the


cardiac monitor not accompanied by a palpable pulse

Hypovolemia
Hypoxia
Acidosis
Hyperkalaemia
Hypokalaemia
Hypothermia
Ingestion of toxic substances
Cardiac tamponade
Tension pneumothorax
Coronary thrombosis
PULMONARY THROMBOSIS

Goldhaber SZ et al. N Engl J Med 2004;350: 2281-2290


EKG Signs

Heart rate > 100


Qr in V1
S1 subtypes S1Q3T3
S1rSr3
S1S2S3
Incomplete RBBB
Clockwise rotation R=S in V4,V5,V6
T wave inversion in V2 or V3
ST elevation in V1

Kucher N et al. European Heart Journal 2003; 24: 1113-1119


Echocardiographic Findings in Major Pulmonary Embolism

Goldhaber S et al. N Engl J Med 2004;350:2281-2290


Transthoracic Echocardiogram

Janssen W et al. N Engl J Med 2005;353:1956-1961


Diagnostic Approach to an Outpatient with a Low Clinical Probability of Pulmonary Embolism,
Using a D-Dimer Assay as the Initial Diagnostic Assay

Fedullo P and Tapson V. N Engl J Med 2003;349:1247-1256


SUGGESTED APPROACH TO PE
Patient with risk factors

Assess Clinical Probability by Wells score

LOOK for clinical signs and symptoms

EKG signs

CXR signs

D-dimer

Echocardiography and CT if you have it

WHEN IN DOUBT TREAT !


MANAGEMEN
T
ANTICOAGULATION THROMBOLYSIS EMBOLECTOMY

Risk stratification

Geneva Prognostic Index

Cancer 2
Hypotension 2
Heart failure 1
Prior DVT 1
Hypoxemia 1
USG proven DVT 1

Wicki J et al. Thromb Haemost 2000; 84: 548-552


Goldhaber SZ, Elliot G. Circulation 2003; 108: 2834-2838

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