Snapshot A 36-year-old woman presents to the emergency department with worsening shortness of breath and pleuritic chest pain. Her symptoms began earlier in the day while she was waiting for her bus to return home. She recently returned from China to the United States for a business meeting. She denies any sick contacts and has not had these symptoms in the past. Medical history is unremarkable. She takes an oral contraceptive and a daily multivitamin. Her temperature is 98.6°F (37°C), blood pressure is 135/82 mmHg, pulse is 112/min, respirations are 24/min, and oxygen saturation is 89% on room air. A CT angiogram performedmed and demonstrates a filling defect in the pulmonary vasculature. She is immediately started on supplemental oxygen and heparin. Introduction Definition mechanical obstruction of the pulmonary vascular secondary to a blood clot typically the blood clot is a thromboembolism from a deep vein thrombosis (DVT) Epidemiology Risk factors prolonged immobilization (e.g., long travel) malignancy thrombophilia pregnancy hormonal contraceptives Etiology DVT (most common) from the veins of the proximal thigh (iliac, femoral, or popliteal) Phlegmasia cerulea dolens a progression from a DVT massive thrombus that can embolize from the proximal ileofemoral vein enlarged, blue, and tender lower extremity Septic embolism from right-heart endocarditis Fat embolism Amniotic fluid embolism Pathophysiology occlusion of the pulmonary vasculature results in hypoxemia and subsequent pulmonary vasoconstriction the increased pulmonary constriction causes an increase in pulmonary vascular resistance, which decreases right ventricular stroke volume leading to increased ventricular oxygen demand right ventricular dilatation decreased left ventricular preload (leading to circulatory failure) poor blood flow to the lung, leading to a ventilation-perfusion mismatch Presentation Symptoms dysnea (most common) pleuritic chest pain cough hemoptysis syncope in cases of a large PE Physical exam tachypnea tachycardia loud P2 hemodynamic instability in cases of a large PE Imaging CT angiography of the chest indication imaging study of choice in the diagnostic evaluation of PE sensitivity of ~90% specificity of ~95% comments chest radiography is typically normal or it may show pleural effusions Hampton hump (wedged-shaped infarct) Westermark sign (avascularity distal to the PE) V/Q scan indication performed if the pre-test probability of PE is high but the patient cannot undergo a CT angiogram (e.g., renal failure, pregnancy, or unavailability) interpretation normal rules out PE high-probability treat with heparin low or intermediate probability if clinical suspicion is high, then get a pulmonary angiography Venous duplex ultrasound of the lower extremities indication to evaluate if there are DVTs Studies ECG findings sinus tachycardia atrial fibrillation right ventricular strain S1Q3T3 presence of S wave in lead I and Q wave and inverted T wave in lead III T-wave inversions in V1-V4 Arterial blood gas findings hypoxemia hypocapnia respiratory alkalosis alveolar-arterial gradient may be elevated D-dimer has a high sensitivity but poor specificity for PE and a high negative predictive value used to rule-out PE if there is a low pre-test probability a positive D-dimer in a low risk patient must be followed by a confirmatory study (CTA chest) Differential Myocardial infarction differentiating factor coronary angiography demonstrating coronary occlusion Costochondritis differentiating factor pain with palpation or movement of the arm Treatment Medical Non-vitamin K anticoagulation indication initial therapy in patients with PE in order to prevent further clot formation treatment should not be delayed medication options (best initial step in high risk patient with obvious PE) low-molecular weight heparin do not give in renal failure unfractionated heparin dose by monitoring aPTT preferred in kidney injury/failure warfarin indication typically given around the same time as a non-vitamin K anticoagulant is given dose based on INR (goal is 2-3) thrombolytic therapy indication performed in patients with PE who are hemodynamically unstable Operative embolectomy indication performed in patients with PE who are hemodynamically unstable and thrombolytic therapy is contraindicated or who fail thrombolysis IVC filter indication performed in patients with PE who have a contraindication or failure of anticoagulation Prognosis Significantly high mortality without treatment Wells' criteria used to assess for risk of pulmonary embolism (sum the points) signs and symptoms of DVT +3 pulmonary embolism (PE) is the most likely diagnosis +3 pulse is 100/min +1.5 surgery within the past 4 weeks or immobilization for the past 3 days + 1.5 previously diagnosed PE or DVT + 1.5 hemoptysis +1 malignancy with treatment in the past 6 months < 2 points low risk 1.3% incidence of PE consider using d-dimer 2-6 points moderate risk 16.2% incidence of PE consider high sensitivity d-dimer or CTA > 6 points high risk 37.5% incidence of PE consider CTA