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Pulmonary Embolism and Deep Venous Thrombosis: Report by 蔡壁如 2001/9/24

1. Pulmonary embolism (PE) and deep venous thrombosis (DVT) are caused by blood clots that form in veins. DVT typically forms in the lower extremities while PE occurs when clots break off and lodge in the lungs. 2. Risk factors for PE and DVT include prior clots, inactivity, surgery or trauma, genetic conditions, cancer, and more. Symptoms of DVT are calf pain and swelling while PE causes shortness of breath, chest pain, and cough. 3. Diagnostic tests include imaging scans, blood tests, and lung scans. Treatment involves blood thinners like heparin and warfarin to prevent clot growth and

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Khaled S. Harb
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70 views17 pages

Pulmonary Embolism and Deep Venous Thrombosis: Report by 蔡壁如 2001/9/24

1. Pulmonary embolism (PE) and deep venous thrombosis (DVT) are caused by blood clots that form in veins. DVT typically forms in the lower extremities while PE occurs when clots break off and lodge in the lungs. 2. Risk factors for PE and DVT include prior clots, inactivity, surgery or trauma, genetic conditions, cancer, and more. Symptoms of DVT are calf pain and swelling while PE causes shortness of breath, chest pain, and cough. 3. Diagnostic tests include imaging scans, blood tests, and lung scans. Treatment involves blood thinners like heparin and warfarin to prevent clot growth and

Uploaded by

Khaled S. Harb
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPT, PDF, TXT or read online on Scribd
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Pulmonary Embolism and

Deep Venous Thrombosis

Report by 蔡壁如 2001/9/24


DVT vs PE
• DVT :
– Begins in the lower extremities
– Originate in the calf near valve cusps or bifurcuti
– 20 ~ 30% clots popliteal, femoral, iliac
– 10% DVT begins in the thigh
• PE :
– Large emboli lodge at the bifurcation
– Smaller emboli into small arteries
– Lower lobe > upper lobe (特別multiple emboli)
– 10 ~ 20% emboli infarction, usually preexisting
cardiopulmonary disease
一、Risk factors

1. Prior venous thromboembolism


2. Bed rest, congestive heart failure, or inactivity
3. Endothelial damage : lower extremity surgery or
trauma
4. Hypercoagulable states : prothrombin mutation,
antithrombin III deficiency, lupus anticoagulant,
and antiphospholipid antibody
5. Malignancy
二、Clinical manifestations

• Symptoms and signs


• Hemodynamic findings
• Differential diagnosis
Symptoms and sign

DVT : calf pain, edema, venous distension,


and pain on passive dorsiflexion of the foot
PE :
dyspnea, chest pain, and cough. tachypnea,
and tachycardia, mild fever below 39℃
hemotysis, pleuritic pain, pleural rub
syncope, chest pain, and dyspnea, RV
dysfunction eg ; RV heave, JV distension,
TR
Hemodynamic finding

• C.O  or 
• RV diastolic pressure 
• RA pressure 
• PAP 
Differential diagnosis

• Small pulmonary embolism :


pneumothorax, congestive heart failure,
hyperventilation, asthma, myocardial
infarction
• Massive pulmonary embolism : RV
infarction, pericardial tamponade,
venous air embolism
三. Laboratory evaluation (1)
• ECG
– 23% normal in small to medium P.E, 6% normal in massive P.E
• Chest X-ray
– Elevation of hemidiaphragm, atelectasis, effusion, margin toward the
hilum
• Noninvasive studies for DVT
– Color flow doppler (Duplex )
– Impedance plethysmography (IPG) or Venous Occlusive
Plethysmography ( VOP )
• D-dimers
– A level below 500 U/ml high negative predictive valve of 91%
三. Laboratory evaluation(2)

• Lung scintigraphy
– 放射性同位素之閃爍造影術

• Pulmonary angiography
– Definitive diagnostic technique in the disease

• Contrast CT
• MRA
四、Prophylaxis for DVT and PE

• Elastic stockings and sequential


compression boots
• Anticoagulation : if no contraindication
• Subcutaneous heparin : mild to moderate risk
• Screening DVT by venous ultrasound : if
Anticoagulation is contraindication
五、Treatment (1) Heparin

– Dose : bolus 75U/Kg


• Keep 18U/Kg/hr, PTT keep 1.5~ 2.5 times
– Duration : 5 ~ 7 days, warfarin overlap in
5th
– Complication :
• hrmorrhage
• Thrombocytopenia 3 ~ 4%
– Contraindication :
• Bleeding
• Thrombocytopenia
• Maligmant pericarditis
五、Treatment (2)

• Low Molecular Weight (LMW)


– Prophylaxis
– Subcutaneous injection
五、Treatment (3)
• Oral anticoagulants (Warfarin)
– PT keep 2.5 time
– Duration :
• 6 week course :calf vein thrombosis
• 3 ~ 6 m course : proximal DVT and PE
• Life-long anticoagulation :
– cancer
– antiphospholipid antibody syndrome
五、Treatment (4)
Thrombolytic therapy
• Indication
– Acute massive PE with hemodynamic compromise
• Objective
– Accelerate clot lysis,  PAP, improve RV function, improve survival
• Contraindication
– Bleeding, Surgery or trauma (10天內)
• Choice of thrombolytic agent
• Complication
– Bleeding
– streptokinase : allergic , mild fever, itching, hypotension (10%)
Thrombolytic agents
Drug FDA approved dose Alternative dose Cost
Streptokinase 250,000U x 20min, 1500,000 U x 1h $ 350
100,000U/h x 24 ~72 hrs

Urokinase 4,400 U/Kg bolus 3,000,000U x 2h $ 2000 ~


4,400 U/Kg/h x 12h 2700

tPA 100mg x 2h 0.6mg/kg x $2,000 ~


3 ~ 15 min 4,200
五、Treatment (5)

• IVC Filters
• Pulmonary embolectomy
– 80% do in the first hour
– Mortality : 57% emergency, 25% semiurgent
Venous Study in SICU (89年)

• Total numbers : 772人次


• DATA :
– Venous Occlusive Plethysmography : 199/24
– Venous Duplex : 573/142

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