Pulmonary EmbolismPulmonary Embolism

Kevin JonesKevin Jones

PGY-3, Emergency MedicinePGY-3, Emergency Medicine

Arrowhead Regional Medical CenterArrowhead Regional Medical Center

July 20, 2011July 20, 2011

EpidemiologyEpidemiology

22ndnd leading cause of sudden, unexpected, leading cause of sudden, unexpected, nontraumatic deathnontraumatic death

650-900,000 PE’s diagnosed each year650-900,000 PE’s diagnosed each year

~200,000 deaths/years due to PE~200,000 deaths/years due to PE

50% of patients with DVT have perfusion 50% of patients with DVT have perfusion defects on nuclear imagingdefects on nuclear imaging

40% of patients with PE have asymptomatic 40% of patients with PE have asymptomatic DVTDVT

SymptomsSymptoms SymptomsSymptoms

DyspneaDyspnea

Chest painChest pain

Others: syncope, seizure-like activityOthers: syncope, seizure-like activity

SignsSigns

TachycardiaTachycardia

TachypneaTachypnea

HypoxiaHypoxia

JAMA 2006;295(2):172-213.

Wells CriteriaWells Criteria Clinical signs of DVTClinical signs of DVT

Recent sx or Recent sx or immobilizationimmobilization

HR >100 bpmHR >100 bpm

Previous h/o PE or DVTPrevious h/o PE or DVT

HemoptysisHemoptysis

MalignancyMalignancy

PE most likely diagnosisPE most likely diagnosis

PointsPoints

33

1.51.5

1.51.5

1.51.5

11

11

33Wells PS, Ginsberg JS, Anderson DR, et al. Use of a clinical model for safe management of patients Wells PS, Ginsberg JS, Anderson DR, et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med. 1998;129:997-1005.with suspected pulmonary embolism. Ann Intern Med. 1998;129:997-1005.

Simplified Revised Geneva Simplified Revised Geneva ScoreScore Age >65Age >65

Previous history of PE or DVTPrevious history of PE or DVT

Sx or Fx within 1 monthSx or Fx within 1 month

Active malignancyActive malignancy

HR 75-94HR 75-94

HR >95HR >95

Unilateral leg edemaUnilateral leg edema

Unilateral leg painUnilateral leg pain

HemoptysisHemoptysis

PointsPoints

11

11

11

11

11

22

11

11

11

Risk Risk factorsfactors

Clinical Clinical signssigns

SymptomSymptomss

Wicki J, Perneger TV, Junod AF, et al. Assessing clinical probability of pulmonary embolism in the Wicki J, Perneger TV, Junod AF, et al. Assessing clinical probability of pulmonary embolism in the emergency ward. Arch Intern Med. 2001;161:92-97.emergency ward. Arch Intern Med. 2001;161:92-97.

PERCPERCAge < 50Age < 50

HR < 100HR < 100

SpO2 > 94%SpO2 > 94%

No unilateral leg swellingNo unilateral leg swelling

No hemoptysisNo hemoptysis

No recent surgery (<4 weeks)No recent surgery (<4 weeks)

No prior PE/DVTNo prior PE/DVT

No oral hormone useNo oral hormone use

Kline JA, Mitchell AM, Kabrhel C, et al. Clinical criteria to prevent unnecessary diagnostic testing in Kline JA, Mitchell AM, Kabrhel C, et al. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost. emergency department patients with suspected pulmonary embolism. J Thromb Haemost. 2004;2:1247-1255.2004;2:1247-1255.

D-dimerD-dimer

Elevated in several disease processes…Elevated in several disease processes…

Different assays have different sensitivitiesDifferent assays have different sensitivities

PE in low-risk patients with a negative D-PE in low-risk patients with a negative D-dimer…dimer…

Thrombus formation >72 hrs before blood Thrombus formation >72 hrs before blood draw (circulating dimer tdraw (circulating dimer t1/2 1/2 = 8 hrs)= 8 hrs)

Subsegmental PESubsegmental PE

D-dimer AssaysD-dimer Assays

Latex-agglutination Latex-agglutination assayassay

Readily availableReadily available

Quick & easy to Quick & easy to performperform

Less expensiveLess expensive

Sensitivity ~80%Sensitivity ~80%

NPV 91%NPV 91%

ELISA assayELISA assay

Technician dependentTechnician dependent

Takes longerTakes longer

More expensiveMore expensive

Sensitivity ~95%Sensitivity ~95%

NPV 99.5%NPV 99.5%

Stein P et al. D-dimer for the Exclusion of Deep Venous Thrombosis and Pulmonary Embolism: A Systematic Review. Ann Intern Med 2004;140:589-602.

DiagnosisDiagnosis

CT Pulmonary AngiographyCT Pulmonary Angiography

V/Q scanV/Q scan

Direct Pulmonary AngiographyDirect Pulmonary Angiography

Lower extremity U/SLower extremity U/S

Sensitivity for PE <40%Sensitivity for PE <40%

Consider in renal insufficiency, contrast Consider in renal insufficiency, contrast allergy, pregnantallergy, pregnant

CT pulmonary CT pulmonary AngiographyAngiography Sensitivity/Specificity ~90%Sensitivity/Specificity ~90%

CTPA use increased 10-fold from 1998-2006CTPA use increased 10-fold from 1998-2006

Incidence increased 81% from 1998-2006 Incidence increased 81% from 1998-2006 (112/100,000) with only 3% mortality (112/100,000) with only 3% mortality reductionreduction

Increased in-hospital antigcoagulation Increased in-hospital antigcoagulation complications during that same time periodcomplications during that same time period

Wiener RS et al. Time trends in pulmonary embolism in the United States: Evidence of Wiener RS et al. Time trends in pulmonary embolism in the United States: Evidence of overdiagnosis.overdiagnosis. Arch Intern Med Arch Intern Med 2011 May 9; 171:831. 2011 May 9; 171:831.Tapson VF. Acute pulmonary embolism: Underdiagnosed and overdiagnosed. [invited Tapson VF. Acute pulmonary embolism: Underdiagnosed and overdiagnosed. [invited commentary] commentary] Arch Intern MedArch Intern Med 2011 May 9; 171:837. 2011 May 9; 171:837.

Massive vs. Submassive Massive vs. Submassive PEPE Massive PE Massive PE = Acute PE with…= Acute PE with…

HypotensionHypotension ( (any singleany single SBP <90) SBP <90)

PulselessnessPulselessness

Bradycardia (HR <40) + shockBradycardia (HR <40) + shock

Submassive PE Submassive PE = Acute PE without = Acute PE without hypotension but signs of RV hypotension but signs of RV dysfunction/myocardial necrosisdysfunction/myocardial necrosis

TreatmentTreatment

AnticoagulationAnticoagulation

Heparin – 80mg/kg IV bolus, then 18mg/kg/hrHeparin – 80mg/kg IV bolus, then 18mg/kg/hr

Lovenox – 1mg/kg SC q12hLovenox – 1mg/kg SC q12h

Arixtra – 5-10mg SC dailyArixtra – 5-10mg SC daily

ThrombolyticsThrombolytics

AlteplaseAlteplase

ThrombolyticsThrombolytics Evidence of circulatory/respiratory insufficiencyEvidence of circulatory/respiratory insufficiency

Hypotension (SBP <90)Hypotension (SBP <90)

Hypoxia (SpO2 <95%)Hypoxia (SpO2 <95%)

Evidence of RV dysfunctionEvidence of RV dysfunction

RV dilation/hypokinesisRV dilation/hypokinesis

Elevated troponin-I (>0.4) or proBNP (>900)Elevated troponin-I (>0.4) or proBNP (>900)

EKG changesEKG changes

FDA-recommended dose: Alteplase 100mg over 2hrsFDA-recommended dose: Alteplase 100mg over 2hrs

Fibrinolysis Fibrinolysis ContraindicationsContraindications

RelativeRelative Age > 75Age > 75

Current anticoagulation useCurrent anticoagulation use

PregnancyPregnancy

Noncompressible vascular puncturesNoncompressible vascular punctures

Traumatic or prolonged CPR >10 minTraumatic or prolonged CPR >10 min

Recent surgery/bleeding w/in 2-4 Recent surgery/bleeding w/in 2-4 wkswks

Poorly controlled HTN >180/110Poorly controlled HTN >180/110

DementiaDementia

Recent Ischemic CVA > 3 monthsRecent Ischemic CVA > 3 months

AbsoluteAbsolute Prior ICHPrior ICH

Known intracranial CV disease Known intracranial CV disease (AVM)(AVM)

Malignant intracranial neoplasmMalignant intracranial neoplasm

CVA within 3 monthsCVA within 3 months

Suspected aortic dissectionSuspected aortic dissection

Active bleedingActive bleeding

Recent surgery of spinal cord/brainRecent surgery of spinal cord/brain

Recent closed-head trauma with Recent closed-head trauma with brain injurybrain injury

Interventional OptionsInterventional Options

Catheter embolectomyCatheter embolectomy

Surgical embolectomySurgical embolectomy

Reasonable for… Reasonable for…

Massive PE if still unstable after fibrinolysisMassive PE if still unstable after fibrinolysis

Massive/Submassive PE if fibrinolysis is Massive/Submassive PE if fibrinolysis is contra-indicated or there is evidence of contra-indicated or there is evidence of adverse prognosisadverse prognosis

No imaging?No imaging?

Aggressive early management if…Aggressive early management if…

High clinical pre-test probabilityHigh clinical pre-test probability

RV dysfunctionRV dysfunction

Sustained hypotension Sustained hypotension (SBP <90 for >15 min or (SBP <90 for >15 min or requiring inotropic support, & not clearly due to another requiring inotropic support, & not clearly due to another cause)cause)

Documentation PearlsDocumentation Pearls

Why patient is not high risk for MI, UA, Why patient is not high risk for MI, UA, Dissection, PEDissection, PE

No Risk FactorsNo Risk Factors

No recent surgeriesNo recent surgeries

No clinical signs of DVTNo clinical signs of DVT

Negative D-dimer or PERCNegative D-dimer or PERC