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Acute Massive Pulmonary Embolism

AMPE


Presentation

  • 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]
  • When compared with other causes of cardiac arrest, patients who survived a massive PE presented a good neurological outcome (cerebral performance category 1 or 2). The Author(s) 2015.[ncbi.nlm.nih.gov]
  • One patient presented with renal cell carcinoma and tumor embolus as suspected cause of PE. Angiographic and clinical outcomes during the hospital stay were evaluated.[ncbi.nlm.nih.gov]
  • We present two young patients with Klippel-Trenaunay syndrome who survived surgical embolectomy after massive PE and cardiopulmonary resuscitation, with good postoperative recovery.[ncbi.nlm.nih.gov]
  • We present a case of an elderly lady who suffered from acute massive pulmonary embolism with hemodynamic compromise successfully treated with AngioVac catheter system (AngioDynamics, Albany, NY) with full recovery.[ncbi.nlm.nih.gov]
Intravenous Drugs
  • After a further 50 mg given over 5 hr (22 patients), the angiographically determined severity of embolism had decreased by 38% from baseline in the intrapulmonary drug group and by 38% in the intravenous drug group.[ncbi.nlm.nih.gov]
  • drugs) Drug-induced lupus anticoagulant Heart failure Hemolytic anemias Heparin-associated thrombocytopenia Homocystinemia Homocystinuria Hyperlipidemias Inflammatory bowel disease Malignancy, especially lung cancer Phenothiazines Prior pulmonary embolism[medical-dictionary.thefreedictionary.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]
  • All patients had hypoxia and dyspnea. No patient had contraindication for thrombolysis. Angiographic findings, duration of lysis, dose of thrombolytics used, and procedural complications were recorded.[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]
  • For commercial reuse, contact [email protected] Abstract With a wide array of manifestations ranging from mild dyspnea to fatal cardiogenic shock, acute pulmonary embolism (PE) remains an enigmatic clinical entity.[pulsus.com]
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]
  • 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]
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]
Pleuritic Pain
  • 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]
Rales
  • 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]
Distended Neck Veins
  • Signs of acute RV dysfunction include distended neck veins, a parasternal heave, an accentuated P2, and a tricuspid regurgitation murmur.[phaonlineuniv.org]
  • 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]
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]
  • 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]
Heart Block
  • One patient developed heart block during the procedure, and further treatment with the RTC was discontinued. Bradycardia occurred in one patient (managed with lidocaine).[ncbi.nlm.nih.gov]
Withdrawn
  • Because of increasing blood loss on the second day after delivery, streptokinase was withdrawn after a total treatment time of 29 h. Total hemorrhage amounted to 8.9 litres.[ncbi.nlm.nih.gov]

Workup

Right Axis Deviation
  • 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 acidosis with circulatory[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]
P Pulmonale
  • pulmonale - RBBB CXR: rules out other pathology, focal oligaemia, wedge density (pulmonary infarction) ABG: reduced PaO2 in keeping with size of PE, metabolic acidosis with circulatory collapse, respiratory alkalosis D-Dimer: reassuring if negative to[lifeinthefastlane.com]
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]

Treatment

  • Some pulmonary arteriograms 1 to 6 months after initial treatment showed minor abnormalities, but others at a later date were normal. Perfusion lung scans carried out 1 to 8 years after initial treatment often showed minor abnormalities.[ncbi.nlm.nih.gov]
  • 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]
  • Under extracorporeal membrane oxygenation support, the patient received pulmonary angiography and underwent open embolectomy for a definitive treatment.[ncbi.nlm.nih.gov]
  • Massive pulmonary embolism with hemodynamic instability is a life-threatening condition requiring immediate treatment. Urgent thrombectomy or thrombolysis is commonly used for the treatment of this condition.[ncbi.nlm.nih.gov]
  • Because of increasing blood loss on the second day after delivery, streptokinase was withdrawn after a total treatment time of 29 h. Total hemorrhage amounted to 8.9 litres.[ncbi.nlm.nih.gov]

Prognosis

  • 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]
  • Patients with RVD have a worse prognosis than those with normal right ventricular function. Consequently, recognizing the RVD at the time of pulmonary embolism is useful for risk stratification and enables more aggressive therapy.[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]

Etiology

  • 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]

Epidemiology

  • 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]
  • 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 hour[coreem.net]
  • Renal Biopsy in 2015--From Epidemiology to Evidence-Based Indications. Am J Nephrol. 2016;43(1):1-19. Jaurretche S, Antongiovanni N, Perretta F.[nefrologiaargentina.org.ar]
Sex distribution
Age distribution

Pathophysiology

  • 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]
  • 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]
  • (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]
  • […] defined as acute PE with obstructive shock or SBP submassive PE is acute PE without systemic hypotension (SBP 90 mm Hg) but with either RV dysfunction or myocardial necrosis those with none of the above severe features are non-massive or low risk PEs PATHOPHYSIOLOGY[lifeinthefastlane.com]

Prevention

  • 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]
  • Management Immediate full anticoagulation followed by long-term anticoagulation, to prevent deep-vein thrombosis and recurrent pulmonary embolism.[medical-dictionary.thefreedictionary.com]
  • These patients are undertreated with intravenous anticoagulation, which prevents the clot from progressing but doesn’t treat the existing clot.[evtoday.com]
  • NEJM 326:1240 CrossRef PubMed Google Scholar Clagett GP, Anderson FAJR, Levine MN et al (1992) Prevention of venous thromboembolism.[link.springer.com]

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