Thrombotic Non thrombotic Fat Air Tumour IV Drug abusers Epidemiology Third

▫ Thrombotic ▫ Non-thrombotic : Fat, Air, Tumour , IV Drug abusers. Epidemiology • Third most common acute cardiovascular disease ▫ After coronary ischemia and stroke • Mortality increases with age and male sex • 10-20% of persons with PE have genetic thrombophilic disorders • Patients with PE are at increased risk (>1.5X) of death within 6 months of diagnosis

Predisposing Factors 1. History of DVT, Concurrent DVT >95% of pt with PE 2. Obesity ~40% (of cases) - risk is 1.7-3.2X versus non- obesity (Primarily women with BMI ≥29 kg/m2) 3. Cancer ~30% 4. Heart Failure ~35% 5. Surgery - perioperative and up to 30 days post surgery, ~20% 6. Tumor Microembolization 6. Fracture ~20% 7. Smoking (>25cigarettes/day) 8. Shock 9. Air Travel - particularly >3100 miles (5000 km) 10. Intake of (high doses of) Estrogen 11. Trauma 12. Pregnancy: peri- and post- partum

Pathogenesis Clot forms at distal site, usually in distal veins in the leg or in pelvic veins Clots migrate to pulmonary vasculature Pulmonary vascular constriction P-HTN Loss of gas exchange surface Lodged thrombi release vasoconstrictors • Jugular venous distension • Right Heart Failure Alveolar Dead Space Ventilated But Not Perfused

Symptoms Syncope • Dyspnea • Tachypnea • Chest Pain • Tachycardia • Pleuritic chest pain Cyanosis Hemoptysis Sudden cardiac arrest with Pulseless Electrical Activity

Wells Clinical Prediction Rule for PE

CXR

Prominent signs on Chest X-ray Atelectasis: The collapse or closure of the lung resulting in reduced or absent gas exchange. It may affect part or all of one lung Hampton hump sign: It occurs within two days as a result of alveolar wall necrosis accompanying alveolar hemorrhage due to pulmonary infarct. It is a wedge-shaped, pleura-based consolidation with a rounded convex apex directed towards the hilus . It is usually encountered at the lower lobes and heals with scar formation. Westermarck Sign: It describes a decrease of vascularization at the periphery of the lungs due to mechanical obstruction or reflex vasoconstriction in pulmonary embolism (oligemia).

CXR Hampton’s Hump Prominent Pulmonary Artery Watermark's Sign Atelectasis

Watermark's Sign A chest radiograph showed a Westermark sign (Panel A, arrow), with a focal area of oligemia in the right middle zone and cutoff of the pulmonary artery in the upper lobe of the right lung. Computed tomographic pulmonary angiography confirmed the presence of a thrombus in the right pulmonary artery (Panel B, arrow), with an occlusive thrombus in the pulmonary arteries of the right upper and middle lobes. Another thrombus could be seen in multiple branches of the left pulmonary artery.

Clinical Presentation • The Classic Triad: ( Pleuritic Pain, Dyspnea, Hemoptysis)  Occurs in less than 20% of patients with documented PE • Three Clinical Presentations • Pulmonary Infarction (Pleuritic chest pain, Pleural rub, Pleural effusion, Hemoptysis: in only 50% of cases, Tachycardia, Tachypnea, Cyanosis) ▫ Sub massive Embolism ▫ Massive Embolism (Around the 10 th day post-op, 2/3 die in the first two hours) 2