CASE PRESENTATION:

MANAGEMENT

EJENOBO O. E.
 Introduction
Pulmonary embolism is a common and
potentially lethal condition
Diagnosis is often missed because patients
with pulmonary embolism present with
nonspecific signs and symptoms.
The patient in question ha
 Diagnostic Approach
Patients suspected of having pulmonary
embolism should undergo diagnostic tests until
the diagnosis is ascertained or eliminated.
Routine laboratory findings are
nonspecific though they may suggest another
diagnosis
Availability of diagnostic tests, cost-effectiveness
and the expertise of radiologists involved in the
diagnosis, appear to be the considerations in the
workup of a patient suspected of having
pulmonary embolism.
 Laboratory Investigations
D-dimer
WBC- normal or elevated
Arterial blood gases-hypoxeamia, hypocapnia,
respiratory alkalosis
Brain natruiretic peptide
Ischaemia modified albumin levels
 Imaging
CT angiography
Pulmonary angiography
V/Q scan
Echocardiography
ECG
Chest x-ray
Doppler Ultrasound of lower limbs
Pts CT
PTs x-ray
 Treatment Options
Anticoagulation
Thrombolysis
Embolectomy
Vena caval filters
 Anticoagulation
Immediate therapeutic anticoagulation is initiated for
patients with suspected pulmonary embolism.
Diagnostic investigations should not delay empirical
anticoagulant therapy.
Unfractionated heparin: recommended in patients
with massive pulmonary embolism, if concerns
regarding subcutaneous absorption arise, severe renal
failure exists, or if thrombolytic therapy is being
considered. Therapeutic level is measured by the aPTT
and should be 1.5x baseline value
LMWH- recommended in acute non-massive PE, have a
greater bioavailability, can be administered by
subcutaneous injections, and have a longer duration of
anticoagulant effect. A fixed dose of LMWH can be
used, and laboratory monitoring of aPTT is not
necessary.
 Anticoagulation
Warfarin started in conjunction with heparin because the
anticoagulant effect of warfarin does not occur until 36-72hours
after administration, and it has an initial paradoxical procoagulant
effect due to reduced levels of proteins C and S. Adequacy of
therapy is assessed using the prothrombin time ratio(INR), target
INR is 2-3
Patients thromboembolic event occurring in the setting of
reversible risk factors, such as immobilization, surgery, or trauma,
should receive warfarin therapy for at least 3 months
Patients with preexisting irreversible risk factors, such as deficiency
of antithrombin III, protein S and C, factor V Leiden mutation and
APL antibody should be placed on long-term anticoagulation
Mr O. O had a bolus dose of unfractionated heparin and was
subsequently placed on subcut enoxaparin and oral warfarin 10mg
daily
 PT/INR chart
Date INR(target 2-3) PT(11-15sec)
15/9/13 3.33 44

16/9/13 1.81 24.5

17/9/13 1.24 17.5

18/9/13 2.16 29

19/9/13 2.11 29
 Treatment options continued
Thrombolysis: should be done in patients with
evidence of hemodynamic compromise, except in
the face of major contraindications due to
bleeding risks
Streptokinase, urokinase, altepase
Patient was given IV streptokinase 250,00IU in 250mls
of N/S over 30minutes then 100,000IU hourly
Embolectomy
Vena caval filters
 Complications
Sudden cardiac death
Obstructive shock
Pulseless electrical activity
Atrial or ventricular arrhythmias
Secondary pulmonary arterial hypertension
Cor pulmonale
Severe hypoxemia
Right-to-left intracardiac shunt
Pulmonary infarction
Pleural effusion
Paradoxical embolism
Heparin-induced thrombocytopenia
Thrombophlebitis
 Problems/Complications
Delayed presentation/diagnosis
Streptokinase not readily available
Pulmonary infarction
Sepsis with respiratory focus- IV ceftriaxone,
oral cefuroxime
Conclusion