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