Pulmonary thrombo-embolism is an important cause of morbidity and mortality, especially among the hospitalized patients. A vast majority of clinically significant pulmonary emboli (PE) arises from deep venous thrombosis.
- Venous disease of the lower extremities.
- Heart failure.
- Recent major surgery.
- Prolonged immobilization.
- Strong family history of thrombosis.
- Pleuritic chest pain
- Inspiratory crackles
- Swelling of calf
- Localized tenderness
- Slight rise in local temperature suggests DVT.
Diagnosis of Thrombo-embolism
Diagnosis is based on Clinical suspicion and General Diagnostic Evaluation
- Blood Complete Exam: Leucocytosis
- E.C.G – To rule out other cardiac causes of tachypnoea, tachycardia
- Arterial Blood Gases: (ABGs)
- Arterial hypoxaemia usually accompanied with hypocapnia.
- Normal PaO2 can occur in 14 % of patients with acute pulmonary embolism.
- Specific Diagnostic Studies
- Ventilation – perfusion (V-Q) lungs scan is indicated in all clinically stable patients with suspected pulmonary embolism.
- Pulmonary Angiography for confirmation & diagnosis and thrombolytic therapy. These facilities are presently available only at a few centers including Punjab Institute of Cardiology.
- X-Ray Chest Absence of vascular marking on the affected side
A- Supportive Care:-Oxygen Therapy
B- Prevention of Recurrent Emboli is the major therapeutic goal.
Anticoagulation: Heparin I/V. A bolus of heparin (80 units/kg) followed by continuous infusion (18 units/kg/hr) titrated individually to achieve an activated partial thromboplastin time (aPTT) between 1½ and 2½ times the control value, continued for 5-10 days. If APTT is not available, clotting time should be monitored with the help of capillary tubes at 2-3 times the baseline level
- Oral warfarin can be given with the initiation of heparin. Starting dose 5 mg / day for first 2 days, followed by daily dose adjusted to the international normalized ratio (INR) of 2.0-3.0. Warfarin should be continued for 3 months.
- I/V heparin should be started immediately on basis of clinical suspicion of PE and without waiting for definitive studies to be obtained.
C- Specific Therapy
- Systemic thrombolytic therapy with Streptokinase, urokinase should be considered in the treatment of patients who have extensive iliofemoral venous thrombosis or acute massive embolism.
- Thrombolytic therapy has not yet been shown to reduce the mortality in patients with DVT or PE.
Pulmonary embolectomy that can only be carried out in cardiac surgery units.