Pulmonary EmbolismSources of Pulm Embolism1. D.V.T
2. Infective endocarditis of right side of the heart
Ÿ 3. Fat embolism Fracture
4. Amniotic fluid embolism
5. Air embolism
C/P of Pulm EmboliAccording to the size of embolism
A- Small sized Embolism
C/P -ve symptoms
but with recurrent embolization and
when >2/3 of vas. bed obliterated
thrombo embolic pulm. Hypertension
Rt sided failure (cor pulmmonal)
= subacute core. P
B- Moderate sized emboli
C/P Pulm infarction.
1. Cough 2. Sputum 3. Chest 4. Dyspnea
blood tinged. Pain, pleuritic.
Local exam Signs of:
a-± Pleural rub.
b- Crepitations may present.
N.B.The lung parenchyma has three sources of O2, pulm. Vs, bronchial Vs and air within alveoli so, the hemodynamics of the lung must be disturbed for a lung infarction to occur on top of pulm. embolism.
InvestigationsRadiological Signs of Pulm Embolism1. Normal X - ray
2. Triangle (wedged shaped opacity) = infarction.
3. Pulm oligemia = massive embolism
4. Pleural effusion
5. Pulm edema
6. Dilated Pulm artery
Ÿ ECG Rt.V. strain (inverted T in V1, V2)
Rt axis deviation, Rt BBB.
Ÿ Pulm angio diagnostic (invasive.)
Ÿ Pulm scan = lung scan
Ventilation + Perfusion
Patient inspires (Xenon) I.V. injection of radio active
gase with radio active material material (Tc)
we detect distribution uptake by pulm. arteries
of these radio active
material with in lung tissue reflect pulmpnary
= reflect ventilation. vascularity
l Normal ventilation scan + Abnormal perfusion scan highly suggestive for pulm. E.
N.BIn pulm fibrosis Abnormal ventilation scan
Abnormal perfusion scanC- Massive Pulm Embolism
= Pulm. embolism obstructing > 50 % of pulm. VasculatureC/P1. Chest Pain (similar to anginal pain)
BI. pr.¯ hypoxia. Rapid distention of
(¯ cop) pulm. artery
2. Shock this because (BI. flow to lung ¯¯ )
¯¯ V.R. to left atrium
3. Cyanosis = hypoxia.
4. Acute Rt sided heart failure
L.L. + + congested neck veins
edema Tender liver
as above + BI. gases¯¯ O2
ttt of Pulm. E.& D.V.T
in post operative. (pelvic surgery)
Electric. Early ambulance.
massage of L.L.
Risky patient antiplatelet
mini dose heparin
ttt of the cause especially pre and post
N.B.risky Patient + surgery mini dose heparin.
5000 U.S.C./12 hr. before and after surgery. Also we can use low molecular weight heparin
II. Resuscitation(in massive embolism)
2. Analgesics Pethidine
3. ttt shock best dobutamine (Rt.V.F.)
4. Cardiac massage (C.P.R)III. Thrombolytic therapy(used with Rt. V. failure and hemodynamic instability)
Ÿ Strepto kinase.
Ÿ Uro kinase.
Ÿ Recombinant tissue. P. A.
(improve pulm. Vasculature as pulm . pr .¯ )
improve Rt.V. efficiency
IV. Anticoagulant(for DVT and Pulm Embolism)
5000, 10.000 U. heparin. I.V. immediately
then heparin 1000 I.U./ hr. I.V. infusion drip.
Heparin infusion is the best ¯ incidence. of hge.
Why? maintained therapeutic
level all over the day
Other methods· 5000 - 7500 U I.V. / 6hrs
· 10,000 U. S.C. / 8hrs
Duration 7-10 days or till pt clinically improved.
* Follow up the P.T.T is adjusted to
P.T.T. be 1.5 - 2 the normal value
Then start oral anticoag. for 3 - 6 m
warfarin 2.5-7.5 mg/d. the dose is adjusted
according to P.T. (1.5 - 2) of the normal value
N.B.I.V.C. interruption or application or the insertion of filter . into I.V.C. if the anticoag. or fibrinolytic therapy is contraindicated or fails to Q thrombo embolism.
Source: Internal Medicine Book of Dr.Osama Mahmoud (Ain Shams University)
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