Pulmonary Embolism

 Pulmonary embolism (PE)

it is not complete but do include key points that we need to know to work in ward. 

pathophysio: 

• it results from DVT - venous thromboembolism
• venous stasis, endothelial injury and hypercoagulability. 

bridging:

• egfr>30: s/c clexane BD
• egFR 15-30 - s/c clexane OD
• eGFR <15 - IVI heparin (kena monitor coag 6 hourly)

• Warfarin affects the APTT & PT value
• Clexane - APTT (to help INR reaches the aim faster)

• Aim INR 2-3, once INR >2, off clexane, bridging complete

1st to 3rd days for warfarin just trial with dose 5mg/5mg/3mg, 

4th day start adjusting dose base on INR

- pharmacist has special counsellor or booklet for the patient to understand the use of warfarin. with constant follow up and also diet suggestions (no green leafy veges)

BOOKLET LINK: for BM, Eng, Chinese

Investigations(Ix):

1. ECG :

look for ST changes S1Q3T3

- deep S wave in lead I, Q wave in lead 3, T inversion in lead 3

- ST depression, RBBB

- P. pulmonale

2. blood Ix: trop t and ck stat

3. basic supportive tx: HFM, transfer to acute bed

request for :

- CXR : hamptoms hump: wedgemark sign, westermark sign: pulmonary oligaemia in the affected segment

- CTPA : thrombi within pulmonary

https://epos.myesr.org/poster/esr/ecr2020/C-04154

- V/Q scan:

• for those who have clot in the past, and have a previous episode before, or those who has acute kidney damage/ckd.
• clear cxr

- ultrasound for lower limb: to rule out lower limb DVT due to long sitting/surgery...

- start DAPT

4. echo:

- look for RV dilation and hypokinesia. - acute rv failure--> increase afterload, rv cannot unload sufficiently causing rv dilated. impinge on LV cause LV to decrease output and supply to CA
- it increases o2 demand which CA could not meet, results in ischemia and necrosis

MASSIVE PE:

HYPOTENSION BP<50 for at least >15MINUTES, HR <40 - usually with evidence of MI and hyocardial dysfunction

Well's score for PE

low<2, mid 2-6, high >6
1. clinical signs of DVT -3
2. previous surgery / long traveeling>4hrs -1.5
3. previous DVT and PE- 1.5
4. HR>100 - 1.5
5. other diagnosis seem less likely -3
6.hemoptysis -1
7. cancer -1

Management (Mx):

anticoagulant

- without hypotension: LWMH, fonda/ DOACS

- unstable/ bleeding: parental anticoag 5-10d, switch to warfarin overlap 3-7d before discontinue heparin when INR >2 for >2d

- continue anticoag for 3-6months

thrombolytic therapy:

STK 25mu if pt high risk massive PE/ with cardiopulmonary arrest.

other mx: 

1. rivaroxaban 15mg BD for 21d then 20mg OD

2. dabigatran (expensive)

Reference:

1. anticoagulant protocol malaysia