Post on 31-May-2015
transcript
PULMONARY EMBOLISM
SIGN & SYMPTOM [THEORY]Symptoms SignsDyspnea(73%)Pleuritic chest pain(66%) Cough(37%)Hemoptysis(13%)
Tachypnea(70%)Rales(51%)Tachycardia(30%) Fourth heart sound(24%) Accentuated pulmonic component of the second heart sound(23%)
seizures, syncope, abdominal pain, fever, productive cough, wheezing, decreasing level of consciousness, new onset of atrial fibrillation
fever(14%)< 39?c>, chest wall tenderness
DDx.
MI ,Cardiac temponade ,Aortic dissection ,severe MR ,Pericardial effusion
Esophageal rupture Spontaneus
pneumothorax ,Pneumonia ,Pulmonary embolism
INVESTIGATION
Physical examination Sign of DVT ,PE
Basic testing CBC ,E’lyte ,BUN ,Cr ,CXR ,EKG
Pulmonary angiogram D-Dimer CT scan /MRI Ventilation-perfusion scan Venous doppler study
CXR
Initial CxR always NORMAL May show – Collapse, consolidation, small pleural effusion, elevated diaphragm.
EKG
PULMONARY ANGIOGRAPHY
CT SCAN
PERFUSION SCAN
Perfusion Mismatch Ventilation
แนวทางการประเมิ�นผู้��ป�วย
INVESTIGATE OF Pt.
Basic lab : CBC ,E’lyte ,BUN ,Cr LFT Coagulogram ,D-dimer CXR ,CT pulmonary ,Blood gas U/S whole Abd. U/S doppler leg EKG ,Echo ,TEE CEA ,Mammogram for cancer screening test
DEFINITE DX.
Pulmonary embolism
CAUSES
Pulmonary embolus is the end result of a deep vein thrombosis or blood clot elsewhere in the body. Most commonly deep vein thrombosis' are seen in the leg, but can also occur in veins within the abdominal cavity or in the arms.
RISK FACTORProlonged immobilization
Extended travel , prolonged bed rest Increased blood clotting potential
Medication ,smoking ,Cancer ,Pregnancy ,Surgery ,Polycythemia ,genetic predisposition
Damage to vessel wallTrauma with or without surgery or
casting
PICTURE OF BLOOD CLOT IS FORMED
INDICATION FOR ADMISSION
Severity of illness & RiskSign & symptomTreatment
Surely appropriate
TREATMENT [Theory]
Anticoagulation (clot-preventing medication) Heparin/LMWH ,Coumadin
Thrombolysis (clot-dissolving medication) Streptokinase ,t-PA
Surgical managementPulmonary thrombectomy
Inferior vena cava filter
การแบ่�งประเภท & การร�กษาSyndrom
eRt. ventricular
dysfunctionอาการนำ�า
การร�กษา
Massive Breathlessnesssyncope cyanosis Hypotension การอุ�ดตั�น >50 %
มิ� Heparin ร�วมิก�บ่thrombolytic therapy หร�อุ mechanical intervention
Moderate ถึ!ง largepulmonary infarction
ความิด�นโลห�ตัปกตั�Perfusion decrease >30%
มิ� Heparin+-thormbolytic therapy or mechanical intervention
การแบ่�งประเภท & การร�กษาSyndrom
eRt.
ventricular dysfunction
อาการนำ�า
การร�กษา
small ถึ!ง moderatepulmonary infarction
ความิด�นโลห�ตัปกตั�Pleuritic chest pain, hemoptysis, pleural rub or lung consolidation; peripheral emboli
ไมิ�มิ�/พบ่น�อุย
HeparinHeparin & NSAIDs
การแบ่�งประเภท & การร�กษาSyndrome Rt.
ventricular dysfunction
อาการนำ�า
การร�กษา
Paradoxical embolism
Sudden systemic emboli event such as stroke
พบ่น�อุย Anticoagulant +closure of right-to-left cardiac
Nonthrombotic embolism
ส่�วนใหญ่�เป*น air, fat, tumor fragments หร�อุ amniotic fluid
พบ่น�อุย ร�กษาแบ่บ่ประค�บ่ประคอุง
ส่ร�ปแนวทางการร�กษาภาวะ ACUTE PULMONARY EMBOLISM
IVC FILTER
If anticoagulant therapy is contraindicated and/or ineffective
TREATMENT [Pt.]
Anticoagulation Clexane Orfarin
LOS
ICD 9 code 415.1 Pulmonary embolism & infarction LOS 4.6 days
Pt.admit 6 days [ in ICU 1 day ]