Pulmonary Thromboembolism

(PTE)
An Elusive Diagnosis

Jamil A. Alarafi, D.O.

1

Goals

Understand the historical context of pulmonary emboli

Comprehend the pathophysiology and know some common

risk factors

Be aware of the clinical features of PE and have a basic

understanding of various diagnostic test

Gain a therapeutic approach to the treatment of PE and

discuss a simplified method in the work-up of PE

Attempt to dispel a few mythsabout pulmonary emboli

2

Perspective
A Common

disorder and potentially deadly

650,000

cases occurring annually

Highest

incidence in hospitalized patients

Autopsy

reports suggest it is commonly missed

diagnosed
3

Perspective

Presentation is often atypical

Signs and symptoms are frequently vague and

nonspecific and rarely classic

Untreated mortality rate of 20% - 30%,

plummets to 5% with timely intervention

Historical Context
Pre-1930s

Heparin

Eugine

Robin article

Historical Context

PIOPED

(Prospective Investigation of
Pulmonary Embolism Diagnosis)

The

Electronic Era, 2000 and Beyond

So What Do We Do ???
Confusing

for Emergency Physician

Do we under diagnose/over diagnose?

Why dont we have a standardized method of
work up after all these years?
7

Pathophysiology
Rudolph Virchow, 1858
Triad:

Hypercoagulability
Stasis to flow
Vessel injury

Risk Factors
Hypercoagulability
Malignancy
Nonmalignant thrombophilia
Pregnancy
Postpartum status (<4wk)
Estrogen/ OCPs
Genetic mutations (Factor V Leiden, Protein C & S deficiency, Factor
Prothrombin mutations, anti-thrombin III
deficiency)

VIII,

Venous Statis

Bedrest > 24 hr
Recent cast or external fixator
Long-distance travel or prolong automobile travel

Venous Injury
Recent surgery requiring endotracheal intubation
Recent trauma (especially the lower extremities and pelvis)

Clinical Presentation
The Classic Triad: (Hemoptysis, Dyspnea, Pleuritic Pain)

Not very common!

Occurs in less than 20% of patients with documented PE

Three Clinical Presentations

Pulmonary Infarction
Submassive Embolism
Massive Embolism

10

Mythology of PE
Myth

Patients with pulmonary embolism are short of breath

and have chest pain!

Reality:

You can forget about making the diagnosis on clinical

grounds, but waitdont plan on completely ruling it
out either!

11

Clinical Features
Symptoms in Patients with Angio Proven PTE
Symptom

Percent

Dyspnea
Chest Pain, pleuritic
Anxiety
Cough
Hemoptysis
Sweating
Chest Pain, nonpleuritic
Syncope

84
74
59
53
30
27
14
13

12

Clinical Features
Signs with Angiographically Proven PE
Sign Percent
Tachypnea > 20/min 92
Rales58
Accentuated S2
53
Tachycardia >100/min 44
Fever > 37.8 43
Diaphoresis 36
S3 or S4 gallop
34
Thrombophebitis
32
Lower extremity edema

24

13

Who do we work up?

- Pretest Probability
Definition:

The probability of the target

disorder (PE) before a diagnostic test result
is known.

Used

to decide how to proceed with

diagnostic testing and final disposition

Gestalt

This is really what it boils down to!

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Diagnostic Test

Imaging Studies
CXR
V/Q Scans
Spiral Chest CT
Pulmonary Angiography
Echocardiograpy

Laboratory Analysis
CBC, ESR, Hgb/Hct,
D-Dimer
ABGs

Ancillary Testing
EKG
Pulse Oximetry

15

Diagnostic Testing
- CXRs
Chest X-Ray Myth:
You have to do a chest x-ray so you can find
Hamptons hump or a Westermark sign.
Reality:
Most chest x-rays in patients with PE are
nonspecific and insensitive
16

Diagnostic Testing
- CXRs
Chest radiograph findings in patient with
pulmonary embolism
Result
Cardiomegaly
Normal study
Atelectasis
Elevated Hemidiaphragm
Pulmonary Artery Enlargement
Pleural Effusion
Parenchymal Pulmonary Infiltrate

Percent
27%
24%
23%
20%
19%
18%
17%

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Chest X-ray Eponyms of PE

Westermark's

sign

A dilation of the pulmonary vessels proximal to the

embolism along with collapse of distal vessels,
sometimes with a sharp cutoff.
Hamptons Hump

A triangular or rounded pleural-based infiltrate with

the apex toward the hilum, usually located adjacent to
the hilum.
18

Radiographic Eponyms
- Hamptons Hump, Westermarks Sign

Westermarks
Sign
Hamptons Hump

19

Diagnostic Testing
EKGs

EKG

Most Common Findings:

Tachycardia or nonspecific ST/T-wave changes

Acute cor pulmonale or right strain patterns

Tall peaked T-waves in lead II (P pulmonale)

Right axis deviation
RBBB
S1-Q3-T3 (occurs in only 20% of PE patients)

20

Diagnostic Testing
- Pulse Oximetry
The

Pulse Oximetry Myth:

You must do a pulse oximetry reading, since

patients with pulmonary embolism are hypoxemic!
Reality:

Most patients with a PE have a normal pulse

oximetry, and most patients with an abnormal pulse
oximetry will not have a PE.
21

Diagnostic Testing
- ABGs

The ABG/ A-a Gradient myth:

You must do an arterial blood gas and calculate the alveolararterial gradient. Normal A-a gradient virtually rules out PE.

Reality:
The A-a gradient is a better measure of gas exchange than the
pO2, but it is nonspecific and insensitive in ruling out PE.

22

Diagnostic Testing
Echocardiography

Consider in every patient with a documented

pulmonary embolism
EKG

maybe helpful in demonstrating right heart

strain

Early fibrinolysis can reduce mortality 50%!

23

Ancillary Test
WBC

Poor sensitivity and nonspecific

Can be as high as 20,000 in some patients

Hgb/Hct

PTE does not alter count but if extreme, consider

polycythemia, a known risk factor
ESR

Dont get one, terrible test in regard to any predictive

value

24

D-dimer Test

Fibrin split product

Circulating half-life of 4-6 hours

Quantitative test have 80-85% sensitivity, and 93-100% negative

predictive value

False Positives:
Pregnant Patients
Post-partum < 1 week
Malignancy Surgery within 1 week
Advanced age > 80 years
Sepsis
Hemmorrhage CVA
AMICollagen Vascular Diseases
Hepatic Impairment

25

Diagnostic Testing
D-dimer

Qualitative

Bed side RBC agglutination test

SimpliRED D-dimer

Quantitative
Enzyme linked immunosorbent asssay Dimertest
Positive assay is > 500ng/ml
VIDAS D-dimer, 2nd generation ELISA test

26

Ventilation/Perfusion Scan
- V/Q Scan
A common

modality to image the lung and its

use still stems from the PIOPED study.

Relatively

noninvasive and sadly most often

nondiagnostic

In

many centers remains the initial test of choice

Preferred

test in pregnant patients

50 mrem vs 800mrem (with spiral CT)

27

V/Q Scan

Technique

Interpretation

Normal
Low probability/nondiagnostic (most common)
High Probability

Simplified approached to the interpretation of results:

High probability
Normal Scan
Everything else

Treat for PE
If low pre-test, your done
Purse another study (CT, Angio)

28

Spiral (Helical) Chest CT

Advantages

Noninvasive and Rapid

Alternative Diagnosis
Disadvantages

Costly ($600 - 900/scan)

Risk to patients with borderline renal function
Hard to detect subsegmental pulmonary emboli
29

Pulmonary Angiography
Gold

Standard

Performed in an Interventional Cath Lab

Positive

result is a cutoff of flow or

intraluminal filling defect

Court

of Last Resort
30

Dr. Batizy explaining

the CT results

Treatment:

Patient
replies:
Uh-huh,
when do I
get to eat!

Goals:

Prevent death from a current embolic event

Reduce the likelihood of recurrent embolic

events

Minimize the long-term morbidity of the event

31

Treatment
Anticoagulants

Heparin

Provides immediate thrombin inhibition, which prevents

thrombus extension

Does not dissolve existing clot

Will not work in patients with antithrombin III def.

In this case use hirudins

Few absolute contraindications

32

Treatment
Anticoagulants

Heparin
Available

as Unfractionated or LMW Heparin

FDA approved dosing:

Unfractionated: 80 units/kg bolus, 18 units/kg/hr
LMWH: 1 mg/kg Q 12 or 1.5mg/kg Q D
LMWH

(Lovenox) prefered in pregnant patients

33

Treatment
Anticoagulants

Warfarin (Coumadin)

Interferes with the action of Vit-K dependent factors: II, VII,

IX, and X, as well as protein C & S

Causes temporary hypercoagulable state in first 5 days of

treatment
Important a patient is anticoagulated with heparin before
initiating warfarin therapy

Target INR is 2.5 3.0

34

Treatment
Fibrinolytic

Therapy (Alteplase)

Indications:

Documented PE with:

Persistent hypotension
Syncope with persistent hemodynamic compromise
Significant hypoxemia
+/- patient with acute right heart strain

Approved Altivase regimen is 100mg as a continuous IV

infusion.

35

Treatment
Embolectomy

Prefininolytic therapy this was only therapy

for massive PE
Carries a 40% operative mortality
Alternative is Transvenous Catheter
Embolectomy
36

A Simplified Algorithm
Pre-test

probability
D-dimer (VIDAS-DD)
CT angiography
Low Pre-test, D-dimer (-),
patient had < 1.7% 90 day
PE occurrence in a Mayo
Clinic Study

37

Special Circumstances
Morbid

Obesity

Pregnancy

V/Q has considerable less radiation

50 mrem vs. 800 mrem

Almost all will have positive D-Dimer

Heparin safe in pregnancy

Witnessed

Cardiac Arrest

Standard ACLS, if known PE, the lytics.

38

Conclusion
Summary Points

Pulmonary Emboli remain a potentially deadly and common event which

may present in various ways

Don't be fooled if your patient lacks the classic signs and symptoms!

Consider PE in any patient with an unexplainable cause of dyspnea, pleuritic

chest pain, or findings of tachycardia, tachpnea, or hypoxemia

2nd Generation Qualitative D-Dimers have NPV of 93-99%

Heparin remains the mainstay of therapy with the initiation of Warfarin to

follow

Simplified Algorithm: ( Pretest probability, D-Dimer, +/- CT angio), then

disposition)

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The End!

Questions????

40

1. Which of the following is not a part of

virchows triad?
a)
b)
c)
d)

Hypercoagulability
Stasis to flow
Vessel injury
History of previous DVT

41

2.

Which of the following is the propper

treatment of fat emboli?
a)
b)
c)
d)

Platelets
High dose steroids
Heparin
cryoprecipitate

42

3.

The Classic Triad of patients presenting

to the ED with PE includes all of the
following except:

a)

Hemoptysis
Dyspnea
+ Homans sign
Pleuritic Pain

b)
c)
d)

43

4.

What is the most common

symptom in a patient with Angio
Proven PTE?

a)

Dyspnea
Chest Pain, pleuritic
Anxiety
Cough

b)
c)
d)

44

5.

What is the most common ecg finding in

patients with PE?
a)
b)
c)
d)
e)

Right axis deviation

RBBB
S1-Q3-T3
Tall peaked T-waves in lead II (P pulmonale)
Sinus tachycardia

45

Answers
1.
2.
3.
4.
5.

D
B
C
A
E

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