pulmonary embolism - iswanto pratanu, md, fiha.pdf

8/18/2019 Pulmonary Embolism - Iswanto Pratanu, MD, FIHA.pdf

1/30

CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015

PULMONARY

EMBOLISM

ISWANTO PRATANU


2/30


Introduction

DVT

VTE

PE

o Acute PE is the mostserious clinical

presentation of VTE

o incidence of 100–200 per

100 000 inhabitants

omortality rate 15% in thefirst 3 months after

diagnosis

oThe epidemiology of PE

is difficult to determine

asymptomatic

(Goldhaber 2003 Merrigan 2013)


3/30


Risk Factor

o Immobilization

o Travel of 4 hours or more in the past month

o Surgery within the last 3 months

o Malignancy (17%)

o History thromboplebitis

o Trauma to lower extremities and pelvis during past 3 mos

o Smokingo Central venous instrumentation within past 3 months

o Stroke

o Prior pulmonary embolism

o Heart failure

o COPD

o Hypercoagulable states (hereditary)

o Hormonal therapy

(Stein 2007) (Ouelette DR 2015)


4/30



5/30


Pathophysiology

Circulation

Gas exchange

Neurohormonals

Pulmonary vascular

obstruction

RV dilatations

Vasoconstriction

↑ pulmonary resistance ↓ compliance artery

Chemical factorsEmbolus

RV heart failure↓ CODesaturation

Disturbance

ventilation-

perfusionHypoxemia

PE

(Goldhaber 2003,

Konstantinides 2014)


6/30


2014 ESC Guidel ines on the diagnosis and m anagement of acute

pu lmonary embol ism


7/30


Diagnosis

Clinical manifestation of PE is not specific

Suspected PE:

•Dyspneu•Chest pain

•Presyncope or syncope

•Haemoptysis (coughing up blood)

•Palpitations

•Leg swelling and discomfort

(Goldhaber 2003)


8/30


Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED)


9/30


(Konstantinides 2014)


10/30


Scoring system

(Wells 2000)


11/30


Scoring system

(La Gal 2006)


12/30


Laboratory Test

D-Dimer

• Suspected low or

intermediate risk of

PE

• ELISA method:

sensitivity 95%

• Specificity decreased

almost 10% in >80

years old

(Vyas 2012, Konstantinides 2014)


13/30


Laboratory Test

BNP

• Increase in about 50% PE patients

• Higher sensitivity as indicator in heart failure

Troponin I or T

• Increase in PE patients

(Binder 2005, Lankeit 2013, Konstantinides 2012)


14/30


Imaging Test

Joseph, Nicholas JR. CE Essentials


15/30


Imaging Test

Echocardiography• Detect morphology dan function changes of RV

• Prognostic value in unstable haemodynamics

patients is still the best

• No sign of RV overload or dysfunction exclude

suspected high risk PE



16/30


Thrombus

Thrombus

Thrombus

Thrombus


17/30


Imaging Test

CT Angiography• Standart imaging for

patient with

suspected PE

• Adequate imaging

pulmonary vascular to segmental level

• MDCT giving

imaging of thrombus

in pulmonary

vascular, detect RVdilatation and RV

dysfunction

(Lucassen 2013, Konstantinides 2014)


18/30



19/30



20/30




21/30




22/30


Therapy

Haemodynamic and Respiratory Support

• Supportive treatment is vital acute RV failure

low systemic output cause of death

• Modest (500 ml) fluid challenge

help increasecardiac index

• Vasopresor is often necessary

• NE improves RV function via direct positive inotropic

effect

• Dobutamine or dopamine considered for patient withlow cardiac index and normal BP



23/30


Therapy

Anticoagulation

• Recommended to

prevent early death and

recurrent symptomatic

or fatal VTE• Standard duration at

least 3 months

• Acute phase treatment

consist of parenteral

UFH, LMWH or fondaparinux over first

5-10 days(Quinlan 2004, Buller2012)


24/30


Therapy -- Thrombolysis

(Konstatinides 2012, Lavorini 2013)


25/30


Therapy

Systemic thrombolysis is not routinelyrecommended as primary treatment for patients

with intermediate-high risk PE, but should be

considered if clinical signs of haemodynamic

decompensation appear

Percutaneous catheter-directed treatment or

surgical pulmonary embolectomy are

alternative rescue procedures for intermediate-

high risk PE

(Konstatinides 2012, Lavorini 2013)


26/30


27/30


Prognostic

(Jimenez 2010, Konstatinides 2014)


28/30


Summary

• PE has high morbidity and mortality• The diagnose of PE is difficult to determine

because remain asymptomatic

• Risk stratification need to be done for suspected PE to determine diagnosis and

therapy

• With prompt diagnosis and management,

recurrent PE and mortality could be prevented


29/30



30/30


THANK YOU

pulmonary embolism - iswanto pratanu, md, fiha.pdf

Documents