Embolism Flashcards
explain the pathophysiology of embolism
impact of a thrumbus in the P.A
the origin of the embolus - dsital to the RA
what is the sources of emboli ?
veins of the lower limb is the most common
rare are the veins of the upper limbs
what are the consequenses
what are the thrombotic material causing embolism?
fibrine
red blood cells
leucocites
platelets
what non-thrombotic material that causes embolizm
bone marrow
air
amniotic fluid
tumoral fragments
exogenous foreign bodies
fat
what are the major risk factors of embolizem ?
major surgery
major trauma
malginancies and the treatment
anterior venous thromboembolism
blood clotting disorders
what are the minjor risk factors
advanged age
pregnancy and postpartum state
estrogens - oral contraceptives
postmenopausal substitution therapy
prolonged immobility
nephrotic syndrome
myeloprolifeative disorders
obesity
stroke
IBD
explain the massive acute pulomonary embolism
occlusion of > 50% of pulmonary circulation
- sudden occlusion -> sudden collapse
- loss of conscioucness
- weak, rapid pulse
- low arterial pressure
- S3, S4
- col, pale skin
- central cyanosis
- jugular vein distanteion
- ventrcular fibrillation
explain the clinical manifestations
massive - circulatory collapse
medium - pulmonaru insufficiency
small, multiple - pulmonary hypertension
massive subacute pulmonary embolsim
- < 50 % vascular occlusion
- Severe, progressive dyspnea (over a few weeks) without cause/dyspnea when resting
- No thoracic pain
- Collapse/syncope - emboli/arithmias/low cardiac output
- Severe RHF/circulatory collapse/sudden death
- Internal jugular vein distention
- ECG - RHV (right ventricular hypertrophy)
- X-ray - pulmonary infarction
Angiography and scintigraphy - perfusion defects
minor acute pulmonaru embolism
- With infarction:
- rare – double vasc. – pulmonary arterial and bronchial
- Pleuritic pain, hemoptysis for a week or more
- pleural fluid/friction rub
- Fever
- Hyperventilation
- X-Ray – condensation/ segmentary atelectasis
- 40% of PI have serosanguinolent/ serous pleural effusion
- Without infarction
- Silent – dyspnea, fever, hyperventilation (possible)
- X-Ray – normal
- ECG – no value
- Low PaO2 and PaCO2
- Scintigraphy: ventilatory – normal; perfusion – hypoperfusion
early angiography – useful, diagnosis in doubt
explain well’s criterai for PE
Signs of DVT - 3 point
Dyspnea + normal X-ray - 3 point
heart rate > 100/min 1.5
immobilization > 3 days/surgery in prev 4 week 1.5
previous episode of PE or DVT 1.5
Hemoptysis 1
malignancy + treatmetn wothin 6 months or palliative 1
low clinical suspicion < 2
intermediary clinical suspicion 2-6
high clinical suspicion > 6
chest X ray marks
normal X-ray + sudden dyspnea = PE
westermarks sign - focal oligemia
Palla’s sign – enlarged right descending pulmonary artery
Pulmonary infarction
Scintigraphy ventilation/perfusion
- of high value for PE if X-Ray is normal
- corroborated with clinical probability – can establish the diagnosis or exclude PE
Doppler ultrasonography
occlusions of the major veins of the lower limbs
Venography
- opaque substance – veins of the lower limbs
- major venous occlusion
- Expensive
Scintigraphy with radioactive fibrinogen (125 Iodine)
- IV isotope, preferrential uptake – inclusion of the radioactive fibrinogen in the fresh thrombus
- very sensitive test
D-dimer ELISA test
- normal levels – exclude VTE in combination with a normal V/P ratio and normal Doppler
- abnormally high also in sepsis or malignancy – requires further testing
Computed tomography
Spiral – thin 1mm slices, one breathing cycle 12-15 – thrombi in the bronchial arteries of the 5th order
Pulmonary angiography
- Invasive (replaced by CT)
- Certainty diagnosis – 1-2 mm emboli
- Secondary signs:
○ Sudden vascular occlusion
○ Slow arterial filling
Segmental oligemia
Differential diagnosis of PE
MI
acute internal hemorrhage
cardiac tamponade
spontaneous pneumothorax
pneumonia, asthma atack, COPD exacerbation
advanced HF
treatment
tormbolysis
heparin
low molecular heparin
what are the complications of heparin therapy?
bleeding
thrombocytopnia
osteopenia
what is the surgical treatment called?
embolectomy
in severe cases
hemodynamic instability
Adjuvant treatment
pain relief (NSAID)
o2
dobutamine - beta-adrenergic agonist, inotropic positive action
treatment of RHF and cardiogenic shock
treatment secondary prevention
- Filter on IVC (inferior vena cava)
decreases the risk of pulmonary embolism for patients that cannot be on anticoagulants or have residual deep venous thrombosis (+/- anticoagulation)
