Pulmonary embolus
Theory
Thrombosis in deep veins of calf, larger veins of leg, or clot in right atrium breaks off and embolises through the right heart into the pulmonary vasculature.
This can be subclinical, result in increased pulmonary vascular resistance and acute right heart failure, give rise to acute symptoms or cause sudden death.
Immediate intern management
Attend patient and make rapid assessment.
If patient unconscious/arrested or in severe respiratory distress
- Tell nursing staff to call Code Blue then move to head end of bed.
- Perform triple manoeuvre – chin lift, jaw thrust, head tilt.
- Clear mouth – suction secretions.
- Insert Guedel airway and bag and mask.
- Check pulse and if arrested start CPR.
If patient conscious
- Administer oxygen by mask to maintain oxygen saturations.
- Perform continuous pulse oximetry.
- Obtain IV access and send off basic blood tests.
- ABG.
- Organise urgent CXR.
- Liaise with senior medical staff – unit registrar and/or medical registrar.
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Risk factors
- Surgery, especially pelvic/orthopaedic
- Immobility
- Malignancy
- OCP/pregnancy/HRT
- Recent AMI/CVA
- Previous thromboembolism, inherited thrombophilia
Clinical features (obtain rapidly)
History
- Basic information about patient
- SOB
- Pleuritic chest pain
- Haemoptysis
Examination
- Tachycardia
- Oxygen saturations
- Sweaty, anxious
- Pleural rub
- If massive embolus:
- Pale and sweaty
- Tachycardia, tachypnoea
- Central cyanosis
- Elevated JVP
- RV heave
- Gallop rhythm (right heart failure)
Investigations
- CXR
- Ensure no other reason for symptoms
- ABG
- Hypoxia, hypercapnia, hypocapnia
- ECG
- S (I), Q (III), T (III) wave changes
- Right heart strain
- V/Q scan
- Gives you a probability based on the degree of ventilation and perfusion mismatch
- CT pulmonary angiogram
- Replacing conventional angiography
- Pulmonary angiogram
- Gold standard
- Largely replaced by CTPA in many centres
Definitive management
- Definitive investigations to confirm diagnosis
- Anticoagulation. Choices are:
- Heparin infusion
- Therapeutic dose Clexane
- If massive PE with signs of right heart strain, consider:
- Thrombolytics to dissolve clot
- Urgent sternotomy, cardiopulmonary bypass and surgical embolectomy
Other considerations
- Consider use of IVC filter in setting of iliofemoral thrombosis to prevent clot propagation
- Prevention is better than cure
- All at-risk surgical patients should be treated with anti-embolic stockings and prophylactic Clexane 20 mg or 40 mg sc daily
- Encourage early mobilisation and discharge from hospital once patient is well
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