pulmonary thromboembolism emily s. southward dvm university of missouri – columbia veterinary...
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Pulmonary Pulmonary ThromboembolismThromboembolism
Emily S. Southward DVMEmily S. Southward DVMUniversity of Missouri – Columbia University of Missouri – Columbia
Veterinary Medical Teaching Veterinary Medical Teaching HospitalHospital
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DefinitionDefinition
Pulmonary thromboembolismPulmonary thromboembolism– One clot or many clots that form at One clot or many clots that form at
distant sites and lodge in the pulmonary distant sites and lodge in the pulmonary vasculature.vasculature.
Pulmonary artery thrombusPulmonary artery thrombus– Clots that form in the pulmonary Clots that form in the pulmonary
vasculature.vasculature. Clots can partially or fully occlude Clots can partially or fully occlude
pulmonary vessels.pulmonary vessels.
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Virchow’s TriadVirchow’s Triad
Venous stasis.Venous stasis. Injury or abnormalities to the vessel Injury or abnormalities to the vessel
wall.wall. Alterations in coagulation properties.Alterations in coagulation properties.
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Venous StasisVenous Stasis
Accumlation of activated Accumlation of activated procoagulants.procoagulants.– ImmobilizationImmobilization– Inadequate cardiac pump.Inadequate cardiac pump.
Promotes thrombus formation.Promotes thrombus formation.
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Vessel Wall InjuryVessel Wall Injury
Acute or chronic injury to vessel Acute or chronic injury to vessel endothelium.endothelium.
Leads to activation of platelets and Leads to activation of platelets and clotting cascade.clotting cascade.
Promotes thrombus formation.Promotes thrombus formation.
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Vessel InjuryVessel Injury
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Platelet AdhesionPlatelet Adhesion
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AggregationAggregation
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Alternations in CoagulationAlternations in Coagulation
Increase in procoagulant factors.Increase in procoagulant factors.– By trauma to vascular wall or By trauma to vascular wall or
extravascular tissues.extravascular tissues.– Releases tissue thromboplastin and Releases tissue thromboplastin and
phospholipid.phospholipid.– Leads to formation of prothrombin Leads to formation of prothrombin
activator.activator.– Prothrombin Prothrombin Thrombin Thrombin
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Alterations in CoagulationAlterations in Coagulation
Decrease in anticoagulant factors.Decrease in anticoagulant factors.– ThrombomodulinThrombomodulin– Antithrombin IIIAntithrombin III– HeparinHeparin– AlphaAlpha22-Marcoglobulin-Marcoglobulin– PlasminPlasmin
Leads to hypercoagulable state by Leads to hypercoagulable state by formation of thrombin.formation of thrombin.
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Thrombosis FormationThrombosis Formation
Platelet nidus at site of injury.Platelet nidus at site of injury. Growth by aggregation of platelets Growth by aggregation of platelets
and fibrin.and fibrin. Activation of clotting cascade.Activation of clotting cascade. Larger growth to a red fibrin Larger growth to a red fibrin
thrombus.thrombus. Thrombus fractures and embolizes to Thrombus fractures and embolizes to
other areas of the body.other areas of the body.
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Predisposing Factors or Diseases Predisposing Factors or Diseases for Development of PTEfor Development of PTE
Hypercoagulable stateHypercoagulable state– Nephrotic syndromeNephrotic syndrome– ImmobilizationImmobilization– AmyloidosisAmyloidosis– Early DICEarly DIC– HyperadrenocorticismHyperadrenocorticism
Capillary fragilityCapillary fragility Activation of clotting cascade.Activation of clotting cascade.
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Predisposing Factors or Diseases Predisposing Factors or Diseases for Development of PTEfor Development of PTE
Hypercoagulable stateHypercoagulable state Capillary fragilityCapillary fragility
– Diabetes MellitusDiabetes Mellitus– Immune–mediated hemolyitc anemiaImmune–mediated hemolyitc anemia– SepsisSepsis– HyperadrenocorticismHyperadrenocorticism
Activation of clotting cascade.Activation of clotting cascade.
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Predisposing Factors or Diseases Predisposing Factors or Diseases for Development of PTEfor Development of PTE
Hypercoagulable stateHypercoagulable state Capillary fragilityCapillary fragility Activation of clotting cascade.Activation of clotting cascade.
– SepsisSepsis– Pneumonia/pyothoraxPneumonia/pyothorax– Heartworm diseaseHeartworm disease– SurgerySurgery– Bacterial endocarditisBacterial endocarditis– NeoplasiaNeoplasia
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Consequences of PTEConsequences of PTE
Respiratory.Respiratory.– Increased alveolar dead space.Increased alveolar dead space.– Hyperventilation.Hyperventilation.– Hypoxemia.Hypoxemia.– Ventilation/perfusion inequality.Ventilation/perfusion inequality.– Intrapulmonary shunts.Intrapulmonary shunts.
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Normal AlveolusNormal Alveolus
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Increased Alveolar Dead SpaceIncreased Alveolar Dead Space
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HypoxemiaHypoxemia
Results from ventilation-Results from ventilation-perfusion inequality, physiologic perfusion inequality, physiologic shunting and increased dead shunting and increased dead space. space.
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Intrapulmonary ShuntsIntrapulmonary Shunts
Blood that has not been to areas of Blood that has not been to areas of ventilated lung and enters systemic ventilated lung and enters systemic circulation without gas exchange circulation without gas exchange taking place. taking place.
Poorly oxygenated blood enters the Poorly oxygenated blood enters the arterial system lowering the PaOarterial system lowering the PaO22..
Not responsive to oxygen therapy.Not responsive to oxygen therapy.
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Ventilation/Perfusion InequalityVentilation/Perfusion Inequality
V/Q inequality occurs when V/Q inequality occurs when distribution of blood is altered to the distribution of blood is altered to the alveoli.alveoli.
OO22 increase in the alveoli and CO increase in the alveoli and CO22 decreases.decreases.
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Hemodynamic ChangesHemodynamic Changes
Increase in pulmonary vascular Increase in pulmonary vascular resistance.resistance.
Increased afterload to the right Increased afterload to the right heart.heart.
Can lead to circulatory collapse and Can lead to circulatory collapse and shock.shock.
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Clinical SignsClinical Signs
Not pathognomonic.Not pathognomonic.– Dyspnea.Dyspnea.– Tachypnea.Tachypnea.– Hemoptysis.Hemoptysis.– Tachycardia.Tachycardia.– Hypoxemia.Hypoxemia.– Sudden death. Sudden death.
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DiagnosisDiagnosis
CBC/Biochemistry results reflect CBC/Biochemistry results reflect primary disease process.primary disease process.
Hypoxemia common but 10% of Hypoxemia common but 10% of patients are normal.patients are normal.
Thoracic radiographs can be normal Thoracic radiographs can be normal and inconclusive.and inconclusive.
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LaRue MJ and Murtaugh RJ. Pulmonary LaRue MJ and Murtaugh RJ. Pulmonary Thromboembolism in Dogs:47 cases (1986-87). Thromboembolism in Dogs:47 cases (1986-87). J J Amer Vet Med Assoc. Amer Vet Med Assoc. 1990 Nov. 15;197(1):1368-1990 Nov. 15;197(1):1368-1372.1372.
Johnson LR Johnson LR et al. et al. Pulmonary Thromboembolism in Pulmonary Thromboembolism in 29 dogs:1985-1995 29 dogs:1985-1995 J Vet Intern Med. J Vet Intern Med. 1999 1999 Jul;13(4):338-345.Jul;13(4):338-345.
Flükiger MA and Gomez JA. Radiographic Findings Flükiger MA and Gomez JA. Radiographic Findings in Dogs with Spontaneous Pulmonary Thrombosis in Dogs with Spontaneous Pulmonary Thrombosis or Embolism. or Embolism. Veterinary Radiology, Veterinary Radiology, Vol.25,No.3 Vol.25,No.3 124-131.124-131.
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Advanced DiagnosticsAdvanced Diagnostics
Pulmonary scintigraphy Pulmonary scintigraphy Pulmonary angiography.Pulmonary angiography.
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Pulmonary ScintigraphyPulmonary Scintigraphy
NoninvasiveNoninvasive Aids in diagnosis of PTE but not Aids in diagnosis of PTE but not
definitive.definitive. Two types- ventilation and perfusion Two types- ventilation and perfusion
scans.scans.
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Perfusion ScanPerfusion Scan
Performed first.Performed first. Normal study rules Normal study rules
out PTE.out PTE. Radionuclide-Radionuclide-
labelled, labelled, macroaggregated macroaggregated albumin in albumin in peripheral vein.peripheral vein.
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Ventilation ScanVentilation Scan
Inhaled radioactive Inhaled radioactive inert gas-senon-inert gas-senon-133 or technetium-133 or technetium-99m.99m.
Patient under Patient under general anesthesia.general anesthesia.
Normal in PTE.Normal in PTE.
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Ventilation/Perfusion ComboVentilation/Perfusion Combo
With PTE the With PTE the ventilation scan ventilation scan would be normal would be normal and the perfusion and the perfusion scan abnormal.scan abnormal.
Suggestive of PTE.Suggestive of PTE.FF
Picture from Picture from WWW.bschsys.org/DiagnositcImaging/nucmd/WWW.bschsys.org/DiagnositcImaging/nucmd/htmhtm
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Normal Human Perfusion ScanNormal Human Perfusion Scan
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Abnormal Human Perfusion Abnormal Human Perfusion ScanScan
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Pulmonary AngiographyPulmonary Angiography
Performed if definitive diagnosis or Performed if definitive diagnosis or exclusion of PTE is required.exclusion of PTE is required.
Requires sedation or general Requires sedation or general anesthesia.anesthesia.
Greater risks.Greater risks. Intraluminal filling defect and sharp Intraluminal filling defect and sharp
cutoff are diagnostic for PTE.cutoff are diagnostic for PTE.
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Pulmonary EmbolusPulmonary Embolus
Human lung.Human lung. Arrow indicates Arrow indicates
abrupt termination abrupt termination of a pulmonary of a pulmonary artery.artery.
Www.brighamrad.Harvard.edu/cases/Www.brighamrad.Harvard.edu/cases/bwh/images.bwh/images.
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TreatmentTreatment
Oxygen therapy.Oxygen therapy. Heparinization 200-300 units/kg Heparinization 200-300 units/kg
subcutaneously every 8 hours.subcutaneously every 8 hours. Streptokinase or TPA.Streptokinase or TPA. Mechanical ventilation.Mechanical ventilation. Long term- warfarin therapy.Long term- warfarin therapy.
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MonitoringMonitoring
Clotting times- want to maintain PTT Clotting times- want to maintain PTT at 1.5-2.5 times normal or and ACT at 1.5-2.5 times normal or and ACT at 1.2-1.4 times normal.at 1.2-1.4 times normal.
Serial arterial blood gas analysis.Serial arterial blood gas analysis. Respiratory rate.Respiratory rate. Central venous pressure.Central venous pressure. All other basic monitoring.All other basic monitoring.
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Complications Of TherapyComplications Of Therapy
Hemorrhage most common. Hemorrhage most common. Not predictable. Not predictable. Protamine therapy indicated with Protamine therapy indicated with
hemorrhage due to heparin.hemorrhage due to heparin. Vitamin K or fresh-frozen plasma in Vitamin K or fresh-frozen plasma in
warfarin therapy.warfarin therapy.
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PrognosisPrognosis
Guarded.Guarded. Improves with early detection and Improves with early detection and
treatment.treatment. Improves each day the patient Improves each day the patient
survives.survives. At risk for more emboli.At risk for more emboli.
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UMC VMTH CasesUMC VMTH Cases
Three in data base.Three in data base.– SadieSadie– MagnumMagnum– KokoKoko
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Sadie BaileySadie Bailey
8-year-old FS mixed breed dog.8-year-old FS mixed breed dog. Presented for weight loss, anemia, Presented for weight loss, anemia,
and anorexia.and anorexia. Weak and lethargic on presentationWeak and lethargic on presentation Hemoabdomen, thrombocytopenia, Hemoabdomen, thrombocytopenia,
and neutrophilia with left shift.and neutrophilia with left shift. Developed severe dyspnea and Developed severe dyspnea and
ventricular tachycardia.ventricular tachycardia.
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Sadie’s Thoracic FilmsSadie’s Thoracic Films
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Sadie’s Thoracic FilmsSadie’s Thoracic Films
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Sadie’s NecropsySadie’s Necropsy
Hepatocellular carcinomaHepatocellular carcinoma Adrenocortical hyperplasiaAdrenocortical hyperplasia Pulmonary thrombois – most lobar Pulmonary thrombois – most lobar
branches effected.branches effected. Renal infarction.Renal infarction.
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Magnum MeeksMagnum Meeks
8-year-old MC doberman pinscher8-year-old MC doberman pinscher Presented for dyspnea of two days Presented for dyspnea of two days
duration.duration. Protein losing nephropathy.Protein losing nephropathy.
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Magnum’s Thoracic FilmsMagnum’s Thoracic Films
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Magnum’s Thoracic FilmsMagnum’s Thoracic Films
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Koko WesterhoffKoko Westerhoff
12-year-old FS dachshund.12-year-old FS dachshund. Presented for lethargy, anorexia, Presented for lethargy, anorexia,
tachypnea, and possible CHF.tachypnea, and possible CHF. History includes diabetes mellitus, History includes diabetes mellitus,
IVDD and cataracts.IVDD and cataracts. PE- Increased BV lung sounds, mild PE- Increased BV lung sounds, mild
crackles, tachycardia, and left crackles, tachycardia, and left systolic murmur.systolic murmur.
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Koko’s Thoracic FilmsKoko’s Thoracic Films
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Koko’s Thoracic FilmsKoko’s Thoracic Films
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Koko’s Pefusion ScintigraphyKoko’s Pefusion Scintigraphy
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Koko’s Pefusion ScintigraphyKoko’s Pefusion Scintigraphy
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Koko’s NecropsyKoko’s Necropsy
Muliple small thrombi in the Muliple small thrombi in the pulmonary vasculature.pulmonary vasculature.
CardiomegalyCardiomegaly
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ThanksThanks
Dr. MannDr. Mann Dr. DodamDr. Dodam Dr. LattimerDr. Lattimer Dr. KunzDr. Kunz
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Questions?Questions?