pulmonary ebolism - diagnostic algorithm and treatment of massive form

Question 1

how can we diagnose pulmonary embolism

Answer 1

WELLs scoring system
GENEVA scoring system

Blood pressure cardiogenic shock- hypotension

heart rate above 100 
immobalisation or previous surgery 
hemoptusis
tumor 
previous clot 

2 level scoring - unlikely
3-6 = moderate risk
6 or more = high risk

1st stage 
ECG 
SHIFT IN ELECTRICAL AXIS -qrs axis greater than 100degrees
prominent S wave in lead I
a Q wave and inverted T wave in lead III
right bundle branch block 
T wave inversion in leads v6 and v4

X ray - enlarged hila
changes distal to occlusion - atelectasis m infiltration
elevated diaphragm , pleural effusion

second stage
D dimer test
if its negative there is no pulmonary embolism
Less than 250 micrograms per liter
if it is greater than that suspects to pulmonary embolism
echocardiography - Mc connell sign hyperkinesis of the apex of the right ventricle
direct visualisation of pulmonary emboli
tricuspid insufficiency

Acid base balance

3rd stage

lung scanning
aggregates of albumin labelled with radionuclide injected intravenously and trapped in pulmonary ed

CT/ANGIOpulmographyGRAPHY - filling defect

venous ultrasound - for DVT

Question 2

treatments for massive form pulmonary embolism ?

Answer 2

blood pressure - dopamine and dobutamine

acute respiratory failure - oxygen

treatemnet for massive PE :
fibrinolytics :
streptokinase - 50000e for 20 min , reduced
urokinase
recombiant tissue plasminogen activator - alteplase , reteplase
surgery

treatment continue with heparin and warfarin
heparin (APTT monitoring - 1.5-3 times above .
if hemorrhagic complaints give protamine sulfate
can give thrombocytopnea)

treatment with heparin discontinued after 3 days and INR theraputic range is between 2-3

Question 3

what is the contraindication of these medication such as fibrinolytic ?

Answer 3

bleeding problems

surgical pulmonary embolectomy

Question 4

what are the new medications for pulmonary embolism

Answer 4

fondaparinux - factor 10a inhibitor -

rivaroxaban - oral facto 10a inihibtor

dabigatran - oral irect thrombin 2a inhibotr

Question 5

when there is bleeding problems what is an alternative to medicine ?

Answer 5

inferior vena cava filtres

Question 6

how can we prevent PE ?

Answer 6

avoid prolonged standing
elastic stockings
elevation of legs

Question 7

what are thetreatemnet fr the non massive pulmonary embolism

Answer 7

heparin Iv -80 unit/kg
with warfarin also
low molecular heparin - enoxaparin - less than 8000Da
APTT monitoring at all times

treatment of heparin is discontinued after 3 days
and INR in therapeutic range of 2-3

with direct thrombin inhibitors - dabigatran

fondaparinux

inhibitors of 10a - rivaroxaban - no need for monitoring