massive pulmonary embolism case presentation
DESCRIPTION
High suspicion for massive pulmonary embolism can be life saving.TRANSCRIPT
MASSIVE PULMONARY EMBOLISMCASE PRESENTATION
DR SYED RAZA
• 35 years old lady teacher• Living with partner• Type I DM – on Insulin, Non smoker• OCP – 6 years• Suddenly collapsed on doorway while preparing to
leave for school.• Possible LOC , No head injury. Partner called for
the ambulance.
IN ER
• Denied any chest pain or palpitation• No history of leg pain or swelling
O/E Conscious , oriented Tachypnoec R/R 36/mt SpO2 – 84% RA HR 128/mt SR BP 94/56 mmHG
• Legs – No signs of DVT• CVS- Normal heart sounds, No rub, possible
systolic murmur left para sternal area• Chest- Lungs – possible decreased air entry
left lung but otherwise clear.• Abdomen and Neuro - Unremarkable
ECHO REPORT
• Grossly dilated RV• Severely hypo kinetic RV free wall• RV apex contracts well• PASP 55 mmHg• Rest normal
• Impression – Massive PE• Thrombolysed with ALTEPLASE • Progress :• BP improved, tachycardia settled and Sp02
normalised almost immediately.• Patient transferred to CCU
ROLE OF ECHO IN SUSPECTED PE
• Not indicated in all suspected PE patients• Not a diagnostic tool for PE (Indirect evidence
only)• Signs not specific for PE (low sensitivity and
specificity)• Should not be overused – findings may be
misleading
INDICATIONS
• Suspected massive PE• Patient haemo dynamically unstable• RV strain on ECG, rise in Troponin or BNP• Other modes of imaging not readily available• Patient pregnant and massive PE is suspected• Immediate Thrombolytic may be indicated• Follow up studies – To assess RV function and
pulmonary artery pressure
Findings – Acute Massive PE
• Dilated RV ( EDD > 30 mm, RV/LV > 1)• Akinetic RV free wall but the RV apex
contracts well (Mc Connel’s sign) – 77% sensitivity and 94 % specificity
• Raised PASP – not more than 60 mmHg• Free floating thrombus in RV (rare)
Findings – Chronic PE
• RV Hypertrophy > RV Dilatation • RV function – reasonable• PASP – more than 60 mmHg
CAUSES OF RV ENLARGEMENT
a. Tricuspid valve disease b. Severe Pulmonary Regurgitation c. ASD d. Pulmonary HPN – Primary and Secondary e. R V Infarction f. Arrhythmogenic RV Dysplasia
(Cardiomyopathy)
EVIDENCE
• Heparin vs Streptokinase - only small studies Strep: all survived Hep: Non survived
Alteplase vs Streptokinase (Alteplase more effective)
Thrombolytic Therapy in patients with stable blood pressure but RV dilatation/dysfunction - Controversial