Skip to Main Content

+

  • • Deep venous thrombosis (DVT) most common source of pulmonary embolism (PE)

    • Uncommon causes of embolism include:

    • -Air (complications from central lines)

      -Fat (long bone fractures, respiratory insufficiency, coagulopathy, encephalopathy, petechiae)

      -Amniotic (during active labor)

      -Tumor emboli from RA or inferior vena cava (IVC)

    • < 10% of PE cause pulmonary infarction

    • Size and frequency of PE determines disease and outcome

    • PE obstructing large pulmonary artery: RV failure

    • PE causes release of vasoactive amines causing severe pulmonary vasoconstriction, increased dead space and hypoxia from right-to-left shunt

    • Reflex bronchial vasoconstriction common

++

Epidemiology

+

  • • 50,000 deaths yearly in United States

    • Third leading cause of death in hospital patients

    • Only 30-40% have suspected DVT

    • PE develops in 60% of untreated proximal lower extremity DVT

++

Symptoms and Signs

+

  • • Dyspnea and chest pain (present in 75%)

    • Tachycardia, tachypnea, altered mental status

    • Classic triad: Dyspnea, chest pain, hemoptysis (15%)

    • Pleural rub and S1Q3T3 rarely found

++

Laboratory Findings

+

  • ABG measurement: Hypoxia with respiratory alkalosis

    ECG: New onset atrial fibrillation, ST/T wave changes, sinus tachycardia

    • Elevated D-dimer levels

++

Imaging Findings

+

  • Chest film: Often normal, may show pulmonary cap

    ECG: May show atrial fibrillation, ischemic changes, or RV strain (S1Q3T3), but usually only sinus tachycardia.

    V̇/Q̇ scan: Sensitivity & specificity of 90%, however, 67% of studies are inconclusive

    Spiral CT: More accurate than V̇/Q̇ scan

    Magnetic resonance angiography: Excellent sensitivity and specificity

    Pulmonary angiogram: Invasive but gold standard

+

  • • Evaluate for other causes of chest pain and hypoxia, such as pneumonia

    • Evaluation may be clouded by other possibilities including postoperative pneumonia, which can make V̇/Q̇ scan nondiagnostic

    • Spiral CT of chest most sensitive and efficient in postoperative patient

+

  • • ABG measurement

    • Chest film

    • Duplex Doppler of lower extremity

    • V̇/Q̇ scan (often inconclusive), cannot be interpreted in face of abnormal chest film

    • Spiral CT of chest accuracy better than V̇/Q̇ and does not need clinical correlation

    • Magnetic resonance pulmonary angiogram

+

  • • Initial stabilization with pressors and ventilatory support

    • Start heparin/low-molecular-weight heparin expediently

    • Consider thrombolytics if large clot burden, sever respiratory compromise, hemodynamic instability

++

Surgery

+

  • • IVC filter

    • Open surgical thrombectomy: High mortality (Trendelenburg procedure)

    • Catheter-based suction embolectomy: only in experienced operators

    • Extracorporeal membrane oxygenation (ECMO) can be a last resort in a critical situation

++

Indications

+

  • • IVC filter

    • -Contraindication to anticoagulation

      -Venous thrombosis extension on anticoagulation

    • Open pulmonary embolectomy

    • -Intractable hemodynamic instability

      -Thrombolytics inadequate or not available

      -Rarely indicated or useful

++

Prognosis

+

  • • Preventable cause of hospital death

++

Prevention

+

  • • DVT prophylaxis in perioperative period

++

References

The PREPIC study group: ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessSurgery Full Site: One-Year Subscription

Connect to the full suite of AccessSurgery content and resources including more than 160 instructional videos, 16,000+ high-quality images, interactive board review, 20+ textbooks, and more.

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessSurgery

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.