We present the case of an 80-year-old female with a floating right heart thrombus in conjunction with an acute massive pulmonary embolism, who presented in cardiogenic shock. We successfully carried out surgical embolectomy. [ncbi.nlm.nih.gov]

• Swelling

  Symptoms of a blood clot include warmth, swelling, pain, tenderness and redness of the leg. The goal of treatment is to break up clots and help keep other clots from forming. [icdlist.com]

  CASE PRESENTATION A 60-year-old male patient, with a history of deep vein thrombosis (DVT), presented to the emergency department in respiratory distress with a blood pressure of 76/30 and swelling in his right calf. [evtoday.com]

  The patient had undergone a left hip resurfacing procedure for severe arthritis eight days before his presentation to the ED, and had complained of increased hip pain and swelling since his discharge four days earlier. [epmonthly.com]

  Symptoms of a blood clot include warmth, swelling, pain, tenderness and redness of the leg. The goal of treatment is to break up clots and help keep other clots from forming. Blocking of the pulmonary artery or one of its branches by an embolus. [icd10data.com]

  Other signs and symptoms that can occur with pulmonary embolism include: Rapid or irregular heartbeat Lightheadedness or dizziness Excessive sweating Fever Leg pain or swelling, or both, usually in the calf caused by a deep vein thrombosis Clammy or discolored [mayoclinic.org]

• Anemia

  […] resulting in a hypercoagulable state Other factors Acute medical illness Central venous instrumentation within the past 3 months Chronic obstructive pulmonary disease Drug abuse (intravenous drugs) Drug-induced lupus anticoagulant Heart failure Hemolytic anemias [medical-dictionary.thefreedictionary.com]

  ADVERTISEMENT His lab results were remarkable for a mild anemia with a hematocrit 35.7%, leukocytosis of 23,000 cells/μL, acute renal insuffiency with a creatinine 1.45 mg/dL, an INR of 1.2 and an elevated troponin to 0.21 ng/mL. [epmonthly.com]

  Effects of anemia and left ventricular hypertrophy on cardiovascular disease in patients with chronic kidney disease. J Am Soc Nephrol 2005;16:1803–1810. 30. Ha JW, Oh JK, Pellikka PA, et al. [kjim.org]

  Myocardial infarction Polycythemia Systemic lupus erythematosus Ulcerative colitis Additional risk factors Risk factors for pulmonary embolism also include the following: Drug abuse (intravenous [IV] drugs) Drug-induced lupus anticoagulant Hemolytic anemias [emedicine.medscape.com]

• Fatigue

  (ruptured ectopic, occult trauma) Basics: ABCs, IV, O 2, Cardiac Monitor and 12-lead EKG Airway, Breathing + Circulation Intubation may be necessary if the patient has significant hypoxia that does not respond to supplemental O 2 or has respiratory fatigue [coreem.net]

  […] depression; and/or 3 – Anteroseptal T-wave inversion Serum biomarkers Elevations in BNP, pro-NT BNP and/or cardiac Troponin (as per Table 1) Common Clinical Sequlae Symptoms Pulmonary hypertension / CTEPH Chronic dyspnea (exertional or rest) Chest discomfort Fatigue [acc.org]

• Leg Swelling

  Symptoms of deep vein thrombosis (DVT), including leg swelling or pain, may be present. Many patients have only mild or nonspecific symptoms and asymptomatic PE is sometimes seen on computed tomography (CT) scanning. [uscjournal.com]

  Ultrasonography of the legs, also known as leg doppler, in search of deep venous thrombosis (DVT). [en.wikipedia.org]

• Inflammation

  Blood tests to look for signs of a heart attack, infection or inflammation. Also, a test for arterial blood gases may be taken, which involves taking the blood sample from an artery rather than from a vein. [patient.info]

  Thrombus formation occurs in venous valve pockets due to a combination of slow flow and endothelial inflammation caused by blood flow turbulence within these pockets. 7,8 These inherent factors, combined with conditions leading to prolonged immobility [journalofclinicaltrialresults.com]

• Dyspnea

  Treatment resulted in immediate angiographic improvement and initial relief of PE symptoms (improvement in dyspnea and oxygen saturation) in 16 of 17 patients. [ncbi.nlm.nih.gov]

  Clinical findings Nonspecific; index of suspicion should be high in patients with dyspnea, tachypnea, or chest pain and risk factors for pulmonary embolism. [medical-dictionary.thefreedictionary.com]

  A73-year-old man was admitted to the intensive care unit because of sudden onset of dyspnea followed by syncope. [circ.ahajournals.org]

  Pulmonary embolism should be suspected in all patients who present with new or worsening dyspnea, chest pain, or sustained hypotension without a clear alternative cause. [nejm.org]

• Tachypnea

  Clinical findings Nonspecific; index of suspicion should be high in patients with dyspnea, tachypnea, or chest pain and risk factors for pulmonary embolism. [medical-dictionary.thefreedictionary.com]

  Mechanism of relief of tachypnea during pressure support ventilation. Chest. 1996;109:1320–7. CrossRefPubMed 5. Mancebo J, Albaladejo P, Touchard D, et al. [mijn.bsl.nl]

  The physical examination can reveal hypotension, tachycardia, tachypnea, or cyanosis. Signs of acute RV dysfunction include distended neck veins, a parasternal heave, an accentuated P2, and a tricuspid regurgitation murmur. [phaonlineuniv.org]

  The most common signs of PE are tachypnea and tachycardia. Many patients appear anxious. Lung exam is often normal but may reveal rales or decreased breath sounds. [uscjournal.com]

  Clinical signs consistent with major PE include transient syncope, cyanosis, elevated jugular venous pressure, tachypnea, unilateral restriction of chest wall movement, fever, and signs of RV dysfunction ( Table 2). [intechopen.com]

• Rales

  Lung auscultation revealed minimal diffuse rales bilaterally. Radial and pedal pulses were intact. Right lower extremity had 1+ pitting edema and Homans' sign was positive. Upper and lower extremities were warm to touch, and there was no cyanosis. [omcr.oxfordjournals.org]

  Lung exam is often normal but may reveal rales or decreased breath sounds. An extremity exam may reveal a palpable cord, unilateral or asymmetric edema, tenderness, warmth, erythema, or superficial venous dilation. [uscjournal.com]

  […] testing. [3] Validated clinical prediction rules should be used to estimate pretest probability of pulmonary embolism and to interpret test results. [4] Physical signs of pulmonary embolism include the following: Tachypnea (respiratory rate >16/min): 96% Rales [emedicine.medscape.com]

• Pleuritic Pain

  The classic presentation for PE with pleuritic pain, dyspnea and tachycardia is likely caused by a large fragmented embolism causing both large and small PEs. [en.wikipedia.org]

  The most common presenting symptom is dyspnea, followed by symptoms of pulmonary infarction, including pleuritic pain, cough, and, less commonly, hemoptysis. Symptoms of deep vein thrombosis (DVT), including leg swelling or pain, may be present. [uscjournal.com]

  pain (44 %), calf or thigh pain (44 %), calf or thigh swelling (41 %), cough (34 %), >2-pillow orthopnoea (28 %), and wheezing (21%) [ 12 ]. [oapublishinglondon.com]

• Painful Cough

  He denied chest pain, cough, hemoptysis, fever, or vomiting. [epmonthly.com]

  The most common presenting symptom is dyspnea, followed by symptoms of pulmonary infarction, including pleuritic pain, cough, and, less commonly, hemoptysis. Symptoms of deep vein thrombosis (DVT), including leg swelling or pain, may be present. [uscjournal.com]

  […] with chest pain. [en.wikipedia.org]

• Cyanosis

  […] pleuritic chest pain apprehension cough haemotypsis leg pain collapse = massive PE acute cardiovascular collapse Examination pale, mottled skin tachypnoea tachycardia signs of DVT hypotension altered LOC elevated JVP parasternal heave loud P2 central cyanosis [lifeinthefastlane.com]

  […] symptoms that can occur with pulmonary embolism include: Rapid or irregular heartbeat Lightheadedness or dizziness Excessive sweating Fever Leg pain or swelling, or both, usually in the calf caused by a deep vein thrombosis Clammy or discolored skin (cyanosis [mayoclinic.org]

  The physical examination can reveal hypotension, tachycardia, tachypnea, or cyanosis. Signs of acute RV dysfunction include distended neck veins, a parasternal heave, an accentuated P2, and a tricuspid regurgitation murmur. [phaonlineuniv.org]

  Upper and lower extremities were warm to touch, and there was no cyanosis. [omcr.oxfordjournals.org]

  Clinical signs consistent with major PE include transient syncope, cyanosis, elevated jugular venous pressure, tachypnea, unilateral restriction of chest wall movement, fever, and signs of RV dysfunction ( Table 2). [intechopen.com]

• S4 Gallop

  gallop: 34% Clinical signs and symptoms suggesting thrombophlebitis: 32% Lower extremity edema: 24% Cardiac murmur: 23% Cyanosis: 19% Testing Perform diagnostic testing on symptomatic patients with suspected pulmonary embolism to confirm or exclude the [emedicine.medscape.com]

• Flank Pain

  Patients with pulmonary embolism may present with atypical symptoms, such as the following: Seizures Syncope Abdominal pain Fever Productive cough Wheezing Decreasing level of consciousness New onset of atrial fibrillation Hemoptysis Flank pain [1] Delirium [emedicine.medscape.com]

• Altered Mental Status

  With more extensive clot burden, findings include hypotension, hypoxemia, altered mental status, and signs of RV strain (distended neck veins, tricuspid regurgitation murmur, accentuated pulmonic component of the second heart sound, right-sided third [uscjournal.com]

  Mental Status 60 Arterial oxyhemoglobin saturation level 20 Class Mortality Risk Class I - < 65 points 0 - 1.6% Class II - 65-85 points 1.7 - 3.5% Class III - 85-105 points 3.2 - 7.1% Class IV - 106-125 points 4.0 - 11.4% Class V - >125 points 10.0 - [intechopen.com]

  Table V Risk Scorefor 30 Day adverse events (adapted from [26]) Prognostic factor Categories Points Altered mental status No 0 Yes 10 Cardiogenic shock on admission No 0 Yes 6 Cancer No 0 Yes 6 BNP [ng/l] < 100 0 100-249 1 250-499 2 500-999 4 > 1000 8 [ncbi.nlm.nih.gov]

(See Workup .) Immediate full anticoagulation is mandatory for all patients suspected to have DVT or pulmonary embolism. Diagnostic investigations should not delay empirical anticoagulant therapy. (See Treatment .) [emedicine.medscape.com]

Troponins are commonly part of the normal workup for chest pain and shortness of breath. [journalofclinicaltrialresults.com]

While most patients with suspected PE will have computed tomography angiography of the chest, on occasion concerns for acute renal injury will prompt workup with ventilation-perfusion scans. [intechopen.com]

Current established regimen for management of pulmonary embolism Anticoagulation When acute PE is considered likely, anticoagulation with heparin should be begun while pursuing the diagnostic workup [61]. [ncbi.nlm.nih.gov]

• Right Axis Deviation

  […] heart strain), -> right axis deviation -> s wave (I and aVL) > 1.5mm -> Q wave in III and aVF -> p pulmonale -> RBBB CXR: rules out other pathology, focal oligaemia, wedge density (pulmonary infarction) ABG: reduced PaO2 in keeping with size of PE, metabolic [lifeinthefastlane.com]

  His electrocardiogram showed wide-complex atrial fibrillation with rapid ventricular rate of 182, right axis deviation, right ventricular hypertrophy and inferior Q waves (Figure 1). The initial EKG also showed an S1Q3T3 pattern. [epmonthly.com]

  The ECG may show: sinus tachycardia: the most common abnormality right heart strain pattern incomplete or complete right bundle branch block prominent R wave in lead V1 right axis deviation T-wave inversion in the right precordial leads +/- the inferior [radiopaedia.org]

  ECG may show either ST-segment abnormalities, T-wave inversion, pseudoinfarct pattern, right axis deviation, RBBB, an S 1 Q 3 T 3 pattern, or pulmonale as signs of pulmonary embolism as in our patient. [omicsonline.org]

  Clinical Signs of RV dysfunction Left parasternal heave Accentuated P2 Murmur of tricuspid regurgitation Distended neck veins Unilateral restriction of chest wall Electrocardiogram Signs of Right Heart Strain RBBB Right axis deviation T-wave in V1-V4 [intechopen.com]

• P Pulmonale

  > ETCO2 to gradient hypoxaemia ECG: -> mostly normal -> sinus tachycardia -> SI, QIII, TIII -> non specific ST changes or TWI in anterior leads (right heart strain), -> right axis deviation -> s wave (I and aVL) > 1.5mm -> Q wave in III and aVF -> p [lifeinthefastlane.com]

  Sinus tachycardia, supraventricular tachyar-rhythmias, the S1Q3T3 pattern, new complete or incomplete right bundle branch block, and p pulmonale are some of the ECG patterns described in association with pulmonary embolism [9, 12]. [ncbi.nlm.nih.gov]

• Electrocardiogram Change

  Patients were monitored for heart rate, blood pressure, rhythm, symptoms, electrocardiogram changes, and rate of perceived exertion (on a 1 to 10 scale, with 10 indicating maximum exertion) at rest and at every stage of the exercise protocol. [kjim.org]

There were two deaths, both within 24 hours of treatment and secondary to PE. One death occurred in a patient who had only minimal thrombus removal after treatment with the RTC and no thrombolysis. [ncbi.nlm.nih.gov]

Abstract Patients who experience hemodynamic collapse after acute massive pulmonary embolism have a poor prognosis. Herein, we report our results with 8 patients and discuss a surgical strategy that can improve perioperative survival. [ncbi.nlm.nih.gov]

Specific problems Pregnancy Diagnosis of pulmonary embolism in pregnancy Treatment of pulmonary embolism in pregnancy Pulmonary embolism and cancer Diagnosis of pulmonary embolism in patients with cancer Prognosis of pulmonary embolism in patients with [escardio.org]

or —Elevation of troponin T (>0.1 ng/mL) Fibrinolysis is reasonable for pts with massive PE and acceptable risk of bleeding complications (IIa/B) Fibrinolysis may be considered for pts with submassive PE judged to have clinical evidence of adverse prognosis [emcrit.org]

Those with “submassive” PE, characterized by only mild RV enlargement/hypokinesis and with no residual leg DVT, likely have a much better prognosis. [phaonlineuniv.org]

Ten patients died because of hypoxemia and hypotension prior to initiation of cardiopulmonary bypass, and seven died of myocardial depression of multiple etiologies. [ncbi.nlm.nih.gov]

[…] therapeutic use, Child, Diagnosis, Differential, Female, Haemophilus Infections/complications, Haemophilus parainfluenzae/isolation & purification, Humans, Male, Pneumococcal Infections/complications, Respiration, Artificial, Respiratory Insufficiency/etiology [rug.nl]

Secondly, a more extensive review is given about the appearance, the etiology and pathogenesis, the pathology, radiology and clinical features of the acute respiratory insufficiency produced by intrapulmonary venous-to-arterial shunts. [tandfonline.com]

In patients with significant cardiac disease, pulmonary symptoms are often ascribed to cardiac etiology, but rarely concomitant PE may be discovered [ 62 ], in which case surgical pulmonary embolectomy may be combined with the operation to treat the primary [intechopen.com]

Pocket Guidelines on Acute Pulmonary Embolism Published in 2014 Reference Acute PE Mobile App with interactive tools Published in 2014 Reference 40 Slides on Acute PE Table of contents: Full Text (ESC Clinical Practice Guidelines) Preamble Introduction Epidemiology [escardio.org]

The latter provides significant benefits in terms of costs, availability and epidemiological control. [debeurs.nl]

Acute pulmonary embolism, part I: Epidemiology and diagnosis. Circulation 2006;114:e28-e32. [pulsus.com]

Kirklin MD Google Scholar Kniffin WD Jr, Baron JA, Barrett J et al (1994) The epidemiology of diagnosed pulmonary embolism and deep venous thrombosis in the elderly. [link.springer.com]

PE Mortality (Wood 2011) Epidemiology: ( Wood 2011 ) Incidence of PE: 600,000/year in the US Contributes to death in up to 200,000 patients Mortality Overall: 15-17% HD Stable: < 5% HD Unstable (Massive PE): 52-63% 2/3 of mortality occurs within 1 st [coreem.net]

Published in 2014 Reference Acute PE Mobile App with interactive tools Published in 2014 Reference 40 Slides on Acute PE Table of contents: Full Text (ESC Clinical Practice Guidelines) Preamble Introduction Epidemiology Predisposing factors Natural history Pathophysiology [escardio.org]

In: Weir EK, Reeves JT (eds) Pulmonary vascular physiology and pathophysiology. Marcel Dekker, New York, p 445 Google Scholar Martin M (1993) PHLECO. [link.springer.com]

(Wood 2011) Pathophysiology: Embolus in the pulmonary arteries causes mechanical obstruction to the right ventricle (RV) leading to RV strain Pulmonary embolus causes neurohormonal mediator release in the pulmonary vasculature contributing to increased [coreem.net]

Emergency Pathophysiology. Jackson, Wyo.: Teton NewMedia, 2003. Print. 4.) Hqmeded-ecg.blogspot.com,. “Dr. Smith’s ECG Blog: Sudden Severe SOB And ST Segment Elevation: What Is The Diagnosis And Treatment?”. N.p., 2015. Web. 31 Dec. 2015. 5.) [aclsmedicaltraining.com]

The role of the host defence response in the progression and outcome of ARDS: pathophysiological correlations and response to glucocorticoid treatment. Eur Respir J. 1996;9:2650–70. CrossRefPubMed 19. Gattinoni L, Pesenti A. [mijn.bsl.nl]

Preoperative angiography was performed in 57% of the cases, and in another ten patients suspected of having pulmonary emboli, angiography prevented unnecessary thoracotomy. Despite their moribund condition, 43% of the embolectomy patients lived. [ncbi.nlm.nih.gov]

Prevention Preventing clots in the deep veins in your legs (deep vein thrombosis) will help prevent pulmonary embolism. [mayoclinic.org]

How can a pulmonary embolism be prevented? This involves preventing a DVT. See separate leaflet called Preventing DVT When You Travel. [patient.info]

In the United States, for instance, 80% of patients will be treated under a preventive regime within the next five years, compared to only 30% today. [debeurs.nl]