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Pulmonary Embolism ( Causes - C/P - Investigations - Treatment )

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Old 03-13-2009, 08:21 AM   post no: 1
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Default Pulmonary Embolism ( Causes - C/P - Investigations - Treatment )



Pulmonary Embolism
Sources of Pulm Embolism
1. D.V.T
2. Infective endocarditis of right side of the heart
3. Fat embolism Fracture
4. Amniotic fluid embolism
5. Air embolism

C/P of Pulm Emboli
According to the size of embolism

A- Small sized Embolism

C/P -ve symptoms
but with recurrent embolization and
when >2/3 of vas. bed obliterated

thrombo embolic pulm. Hypertension
Rt sided failure (cor pulmmonal)
= subacute core. P
B- Moderate sized emboli

C/P Pulm infarction.
1. Cough 2. Sputum 3. Chest 4. Dyspnea
blood tinged. Pain, pleuritic.
Local exam Signs of:

a-
Pleural rub.
b- Crepitations may present.

N.B.
The lung parenchyma has three sources of O2, pulm. Vs, bronchial Vs and air within alveoli so, the hemodynamics of the lung must be disturbed for a lung infarction to occur on top of pulm. embolism.

Investigations
Radiological Signs of Pulm Embolism
1. Normal X - ray
2. Triangle (wedged shaped opacity) = infarction.
3. Pulm oligemia = massive embolism
4. Pleural effusion
5. Pulm edema
6. Dilated Pulm artery
ECG Rt.V. strain (inverted T in V1, V2)
Rt axis deviation, Rt BBB.
Pulm angio diagnostic (invasive.)
Pulm scan = lung scan

Lung scan

Ventilation + Perfusion
Scan Scan
Patient inspires (Xenon) I.V. injection of radio active
gase with radio active material material (Tc)

we detect distribution uptake by pulm. arteries
of these radio active
material with in lung tissue reflect pulmpnary
= reflect ventilation. vascularity


l Normal ventilation scan + Abnormal perfusion scan highly suggestive for pulm. E.
N.BIn pulm fibrosis Abnormal ventilation scan

Abnormal perfusion scan
C- Massive Pulm Embolism

= Pulm. embolism obstructing > 50 % of pulm. Vasculature
C/P
1. Chest Pain (similar to anginal pain)
BI. pr.
hypoxia. Rapid distention of
(
cop) pulm. artery
angina
2. Shock this because (BI. flow to lung
)
V.R. to left atrium
cop.
3. Cyanosis = hypoxia.
4. Acute Rt sided heart failure
L.L. + + congested neck veins
edema Tender liver

Investigations

as above + BI. gases
O2

ttt of Pulm. E.
& D.V.T

I. Prophylactic

avoid recumbency
in post operative. (pelvic surgery)


Electric. Early ambulance.
massage of L.L.
Risky patient antiplatelet
mini dose heparin

ttt of the cause especially pre and post
operative

N.B.
risky Patient + surgery mini dose heparin.
5000 U.S.C./12 hr. before and after surgery. Also we can use low molecular weight heparin

II. Resuscitation
(in massive embolism)
1. O
2

2. Analgesics Pethidine
3. ttt shock best dobutamine (Rt.V.F.)
4. Cardiac massage (C.P.R)
III. Thrombolytic therapy
(used with Rt. V. failure and hemodynamic instability)
Strepto kinase.
Uro kinase.
Recombinant tissue. P. A.
Value

(improve pulm. Vasculature as pulm . pr .
)
improve Rt.V. efficiency

IV. Anticoagulant
(for DVT and Pulm Embolism)
5000, 10.000 U. heparin. I.V. immediately
then heparin 1000 I.U./ hr.
I.V. infusion drip.
Heparin infusion is the best
incidence. of hge.
Why? maintained therapeutic
level all over the day

Other methods
5000 - 7500 U I.V. / 6hrs
10,000 U. S.C. / 8hrs
Duration 7-10 days or till pt clinically improved.
* Follow up the P.T.T is adjusted to
P.T.T. be 1.5 - 2 the normal value

Then start oral anticoag. for 3 - 6 m
warfarin 2.5-7.5 mg/d. the dose is adjusted
according to P.T. (1.5 - 2) of the normal value

N.B.
I.V.C. interruption or application or the insertion of filter . into I.V.C. if the anticoag. or fibrinolytic therapy is contraindicated or fails to Q thrombo embolism.

Source: Internal Medicine Book of Dr.Osama Mahmoud (Ain Shams University)











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