Pulmonary embolism
Rivaroxaban
factor Xa inhibitor treatment for DVT
coumadin for DVT
for patients with HIP Fx/ THR use when heparin is not effective
CT angiogram
* gold standard - proximal clots: better than V/Q - peripheral clots: may use V/Q
EKG
*new onset A fib sinus tachycardia, right axis deviation, p pulmonale, S1Q3T3, RBBB
surgical embolectomy
- contraindication to thrombolytics - very high M/M
DVT prophylaxis
- expected immobility - especially in patients with impaired pulm/card status, prior P.E., CHF, Hip fracture, burns, pregnancy
Low molecular weight heparin
- expensive - lower incidence of H.I.T than Std. Heparin if there is already H.I.T then LMWH can NOT be substituted
argatroban
- for patients with HIT or heparin allergy - direct thrombin inhibitor - hepatic clearance - conversion to coumadin- target INR is about 4
DVT prophylaxis treatment
- fractional heparin - low dose conventional heparin - coumadin - intermittent device
Treat PE
- full dose heparin, followed by coumadin - less severe cases: fractionated heparin, then coumadin - argatroban - vena cava interruption - thrombolytic - surgical embolectomy
PE outcomes
- heparin/ coumadin- don't sissolve clot, prevents new clot formation - body takes care of clot - many resolve with not sequelae - concerned with recurrent, sub acute clots which could overwhelm lysis system
what causes a hypercoaguable state?
- hereditary - acquired - pregnancy - Hormone replacement therapy (birth control)
Vena caval interruption
- indicated when there is contraindication to anticoagulation - failure of Std. anticoagulation - unacceptable residual clot burden or large initial clot - may require anticoagulation - don't remove filters
Fractionated heparin
- no major oxygenation problems - no hypotensive issues - no dysrhythmias - limit use if renal impairment
Probability of recurrent P.E.
- non floating DVT: 3% - floating DVT/ no PE: 13% - PE/ non floating DVT: 11% - PE/ floating DVT: 39%
pulse ox
-unreliable - look at the patient
thrombolytic contradictions
1) active bleeding 2) significant recent bleeding 3) recent surgery 4) recent CPR 5) major intracranial processes- uncontrolled hypertension
predispositions
1) immobility 2) vascular intimal injury 3) hypercoaguable state also called virchows triad
Treatment duration
3-6 months -if lifelong predisposing factors- treatment should be LIFE LONG
HIT
Heparin Induced Thrombocytopenia - autoimmune mediated destruction of platelets - less likely with fractionated heparin - if occurs must stop all forms of platelets
helical CT scan
Initial screening for PE, more sensitive for proximal emboli
Ventilation/ perfusion scan
Negative: RULES OUT PE -can be used on dye allergic or renally impaired patients -can serve as a baseline High probability- mismatched lobar perfusion defect Indeterminate- abnormal in area of known CXR abnormality
d dimer
Normal: RULES OUT PE Not normal: doesn't neceessarily rule in PE - can be elevated in various conditions, not specific
Lower Extensor venous dopplers
Will NOT document P.E. - can be positive even if leg exam is neg - may be only documented finding, should not be ignored
ABG
normal ABG (normal PCO2) rules out P.E - assuming patient doesn't have OBSTRUCTIVE LUNG DISEASE (chronic CO2 elevation)
further work up
ventilation/perfussion scan,non-invasive imaging of legs (ultrasound), CT angiogram of chest WITH contrast, conventional pulmonary arteriogram
immediate evaluation
- pulse ox (careful) - EKG - chest x-ray - ABG - Labs- D-dimer - may see mild leukcytosis
Echocardiogram
- shows evidence of RV dysfunction or pulmonary hypertension
symptoms of PE
- sob - chest pain (sharp & pleuritic) - hemoptysis - palpitations - fever - leg pain/ swelling - pressure like chest pain - syncope
Intermittent compression devices
- use on lower extremities when heparin is contraindicated in presence of H.I.T.
V/Q scan
high probability - 2 or more segmental defects - 2 or more subsegmental + 1 segmental - 4 or more subsegmental defects
thrombolytics
indications: heparin failure - or hemodynamic/ respiratory instability from current clot - still need to uses heparin/ coumadin/ or VCF with
CXR
pleural effusion, infiltrate, Hampton's hump, diminished vascularity, prominent pulmonary arteries