Pulmonary embolisim

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Information about Pulmonary embolisim
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Published on October 30, 2008

Author: ramachandran

Source: authorstream.com

DISCUSSION : DISCUSSION Acute pulmonary embolism Factors predisposing PE : Factors predisposing PE Surgery, trauma Obesity Oral contraceptives, pregnancy, postpartum, Cancer, cancer chemotherapy Immobilization (stroke, ICU patients) Indwelling central venous catheters Inherited predisposition to hypercoagulability (resistance to activated protein C; Favtor V Leiden) Clinical manifestations : Clinical manifestations Acute onset of dyspnoea (increase in alveolar dead space, decrease in pulmonary compliance, reflex bronchoconstriction, lung edema), tachypnea Pleuritic chest pain, hemoptysis, cough, rales, wheezing Accentuation of P2 sound, fixed split S2, tachycardia, fever Right ventricular dysfunction (bulging neck veins, increased central venous pressure, RV hypokinesia) (usual cause of death in PE) Manifestasions of PE under anesthesia: Hypoxemia, Hypotension, Tachycaria, Bronchospasm Differential diagnosis : Differential diagnosis Pneumonia Asthma Exacerbation of COPD Pulmonary edema Thoracic aortic dissection Pericardial tamponade Myocardial infarction Pneumothorax anxiety Diagnosis : Diagnosis ECG: S1-Q3- T3 pattern, peaked P wave, new onset atrial fibrillation, RBBB, inverted T wave in V1-V4 (only in massive PE with acute corpulmonale) CXR: a near normal CXR ABG: hypoxia, hypocapnea (hyperventilation due to reflex stimulation of irritant receptors) plasma D dimer, ventilation perfusiopn scan (principal imaging test for PE), venous ultrasonography (to confirm DVT), CT with contrast (large and more central PE), Echocardiography (dilation of RV, RA, PA, RV hypokinesias) Invasive studies: pulmonary arteriography and contrast phlebography Slide 6: D-Dimer High Normal Stop work-up Lung scan Normal Stop work-up nondiagnostic High probability: Treat Leg U/S Normal PAgram Definite DVT: Treat Treatment : Treatment Primary therapy Clot dissolution with thrombolysis (100 mg of recombinant tissue PA as IV infusion over 2 hrs, contraindications: recent surgery, trauma and intracranial disease Pulmonary embolectomy under cardiopulmonary bypass ( massive pulmonary embolism unresponsive to medical management) Secondary prevention Heparin 5000 to 10000units bolus followed by continuous infusions 1000 to 1500 units/hr (goal APTT twice the control value) Warfarin ( goal INR: 3) Inferior venacaval filter Adjunctive therapy : Adjunctive therapy Hypotension (low cardiac output): ionotropes isoproterenol, dopamine or dobutamine: with positive ionotropic and pulmonary vasodilating effect Volume loading cautiously as increased RV dilatation can lead to further reduction in LV forward output Intubation and controlled ventilation with PEEP Management of anesthesia : Management of anesthesia Support vital organ function Minimize anesthesia induced myocardial depression Monitoring arterial and cardiac filling pressures Avoid NO Consider potential adverse effects of ketamine on pulmonary vascular resistance Significant hemodynamic improvement occurs postoperatively

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