GEMC: Pulmonary Embolism Part 2: Resident Training

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Information about GEMC: Pulmonary Embolism Part 2: Resident Training

Published on March 2, 2014

Author: openmichigan



This is a lecture by Dr. Rockefeller Oteng from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License:

Project: Ghana Emergency Medicine Collaborative Document Title: Pulmonary Embolism Part 2 (2012) Author(s): Rockefeller A. Oteng, M.D., University of Michigan License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1  

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Pulmonary  Embolism  Part  2   Rockefeller  A.  Oteng   Ghana  Emergency  Medicine   Collabora@ve  

Diagnos@c  Evalua@on   •  •  •  •  •  •  •  •  •  •  •  •  Wells  Clinical  Predic.on  Rule  for  Pulmonary  Embolism  (PE)     Clinical  feature                                                                                                                                        Points   Clinical  symptoms  of  DVT                                                                                                          3   Other  diagnosis  less  likely  than  PE                                                                            3   Heart  rate  greater  than  100  beats  per  minute                                  1.5   Immobiliza@on  or  surgery  within  past  4  weeks                                1.5   Previous  DVT  or  PE                                                                                                                                  1.5   Hemoptysis                                                                                                                                                              1   Malignancy                                                                                                                                                                1                                                                                                                                                  Total  points       PE  =  pulmonary  embolism;  DVT  =  deep  venous  thrombosis.   Risk  score  interpreta@on  (probability  of  PE):     >6  points:  high  risk  (78.4%);     2  to  6  points:  moderate  risk  (27.8%);     <2  points:  low  risk  (3.4%)    

Diagnos@c  Evalua@on   Wells  Clinical  Predic.on  Rule  for  Deep  Venous  Thrombosis  (DVT)     Clinical feature Points Active cancer (treatment within 6 months, or palliation) 1 Paralysis, paresis, or immobilization of lower extremity 1 Bedridden for more than 3 days because of surgery (within 4 weeks) 1 Localized tenderness along distribution of deep veins 1 Entire leg swollen 1 Unilateral calf swelling of greater than 3 cm (below tibial tuberosity) 1 Unilateral pitting edema 1 Collateral superficial veins 1 Alternative diagnosis as likely as or more likely than DVT -2 Total points DVT  =  deep  venous   thrombosis.   Risk  score   interpreta@on   (probability  of  DVT):     >/=3  points:  high  risk   (75%);     1  to  2  points:   moderate  risk  (17%);     <1  point:  low  risk   (3%).    

Diagnos@c  Evalua@on   •  Laboratory:   –  Rou@ne  laboratory  findings  are  nonspecific.     –  Include  leukocytosis   –  Increased  erythrocyte  sedimenta@on  rate  (ESR),   and  an  elevated  serum  LDH  or  AST  (SGOT)   –  normal  serum  bilirubin.  

Diagnos@c  Evalua@on   •  Arterial  blood  gas   –   Arterial  blood  gas  (ABG)  measurements  and  pulse   oximetry  have  a  limited  role  in  diagnosing  PE.     –  ABGs  usually  reveal  hypoxemia   •   Hypocapnia,   •  Respiratory  alkalosis.  

Diagnos@c  Evalua@on   •  Troponin  :   –  Serum  troponin  I  and  troponin  T  are  elevated  in   30  to  50  percent  of  pa@ents  who  have  a  moderate   to  large  pulmonary  embolism.   –   Presumed  mechanism  is  acute  right  heart   overload.     •  Brain  Nature.c   –  Very  non  specific  pep@de     –  Large  eleva@on  can  suggest  poor  prognosis  

Diagnos@c  Evalua@on   •  Electrocardiogram   –  ECG  abnormali@es  common  in  pa@ents  with  and   without  PE     –  limi@ng  the  diagnos@c  usefulness  of  the  ECG   –  Most  common  Ekg  finding  is  a  sinus  tachycardia   •  Or  non  specific  ST  and  T  wave  changes   –  abnormali@es  historically  considered  to  be   sugges@ve  of  PE   •   S1Q3T3  pa_ern,  right  ventricular  strain,  new   incomplete  right  bundle  branch  block      

Diagnos@c  Evalua@on   •  V/Q  scan  :   –  The  most  extensive  evalua@on  of  the  accuracy  of   the  ven@la@on-­‐perfusion  (V/Q)  scan  was  the   Prospec@ve  Inves@ga@on  of  Pulmonary  Embolism   Diagnosis  (PIOPED)   –  Accuracy  was  based  on  comparison  with  the  gold   standard  test  of  Pulmonary  angiogram   –  The  found  clincally  accuracy  was  best  when   combined  with  pretest  probabili@es  

Diagnos@c  Evalua@on   •  V/Q  scan  :   •  Pa@ents  with  high  clinical  probability  of  PE   and  a  high-­‐probability  V/Q  scan  had  a  95   percent  likelihood  of  having  PE   •  Pa@ents  with  low  clinical  probability  of  PE  and   a  low-­‐probability  V/Q  scan  had  only  a  4   percent  likelihood  of  having  PE   •  A  normal  V/Q  scan  virtually  excluded  PE  

Diagnos@c  Evalua@on   •  Ultrasound:   –  In  some  pa@ents  clinicians  have  a_empted  to  use   lower  extremity  Doppler's  to  evaluate   –  Studies  show  that  many  pa@ents  with  PE  are   missed   –  Bilateral  lower  extremity  doppler’s  will  decrease   the  rate  of  missed  DVT     –  Operator  dependent  

Diagnos@c  Evalua@on   •  D-­‐dimer:   –  D-­‐dimer  is  a  degrada@on  product  of  cross-­‐linked  fibrin.  It   can  be  detected  in  serum  using  a  variety  of  different   assays:   –  Enzyme-­‐linked  immunosorbent  assay  (ELISA)  (results  in  >8   hrs)   –  Quan@ta@ve  rapid  ELISA  (results  in  30  min)   –  Semi-­‐quan@ta@ve  rapid  ELISA  (results  in  10  min)   –  Qualita@ve  rapid  ELISA  (results  in  10  min)   –  Quan@ta@ve  latex  agglu@na@on  assay  (results  in  10  to  15   min)   –  Semi-­‐quan@ta@ve  latex  agglu@na@on  assay  (results  in  5   min)  

Diagnos@c  Evalua@on   •  D-­‐Dimer:   •  For  the  quan@ta@ve  assays,  a  level  >500  ng/ mL  is  usually  considered  abnormal     •  They  are  best  characterized  as  having  good   sensi@vity  and  nega@ve  predic@ve  value   •  Poor  specificity  and  posi@ve  predic@ve  value.  

Diagnos@c  Evalua@on   •  Angiography  :   –  Pulmonary  angiography  is  the  defini@ve  diagnos@c   technique  or  "gold  standard"  in  the  diagnosis  of   acute  PE.     –  It  is  performed  by  injec@ng  contrast  into  a   pulmonary  artery  branch  ajer  percutaneous   catheteriza@on,  usually  via  the  femoral  vein.  A   filling  defect  or  abrupt  cutoff  of  a  small  vessel  is   indica@ve  of  PE.  

Diagnos@c  Evalua@on   •  Angiography:   –  A  nega@ve  pulmonary  angiogram  excludes   clinically  relevant  PE.   –  Pulmonary  angiography  is  generally  safe  and  well   tolerated  in  the  absence  of  hemodynamic   instability  caused  by  acute,  severe  pulmonary   hypertension     –  Radia@on  exposure  depends  on  the  length  and   complexity  of  the  procedure,  and  greater  than  CT.  

Source  Undetermined  

Diagnos@c  Evalua@on   •  Spiral  CT:   –  Spiral  (helical)  CT  scanning  with  intravenous   contrast  (  CT  pulmonary  angiography  or  CT-­‐PA)  is   being  used  increasingly  as  a  diagnos@c  modality   for  pa@ents  with  suspected  PE     –  Ini@al  reports  suggested  that  98  percent  of   pa@ents  with  PE  were  detected  by  CT-­‐PA;   however,  that  value  decreased  to  53  to  87   percent  in  subsequent  studies  

Source  Undetermined  

Source  Undetermined  

Source  Undetermined  

Source  Undetermined  

PERC   •  The  following  eight  factors  cons@tute  the  PE  rule-­‐out   criteria  (PERC):   •  Age  less  than  50  years   •  Heart  rate  less  than  100  bpm   •  Oxyhemoglobin  satura@on  ≥95  percent   •  No  hemoptysis   •  No  estrogen  use   •  No  prior  DVT  or  PE   •  No  unilateral  leg  swelling   •  No  surgery  or  trauma  requiring  hospitaliza@on  within   the  past  four  weeks  

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