Internal Medicine

Pulmonary embolism (PE)

should be considered in anyone presenting with:

👉Breathlessness

👉chest pain

👉cough/haemoptysis

👉hypotension (this occurs if embolism sufficient to compromise cardiac output)

👉DVT

✅ Classification of PE

☑️ Massive PE

👉sustained hypotension [systolic blood pressure <90 mm Hg for at least 15 minutes, not due to arrhythmia, hypovolemia, sepsis, or left ventricular dysfunction]

👉pulselessness

👉persistent profound bradycardia (heart rate <40 bpm with signs or symptoms of shock).

☑️Submassive PE

👉systolic blood pressure >90 mm Hg

👉 RV dysfunction or myocardial necrosis.

☑️Low risk PE

Acute PE and the absence of the clinical markers of adverse prognosis that define massive or submassive

✅ Management

1️⃣ Resuscitatation

👉 Respiratory : Consider supplemental oxygen to keep the SaO2 more than 90%.

👉 Circulation : intravenous fluid administration is first-line therapy.

👉Vasopressor/Ionotropic Support :

Early vasopressor/ionotropic therapy should be considered to support the circulation in case of failure of response to fluid therapy.combination of dobutamine with noradrenaline seems to be ideal .

2️⃣ Empirical anticoagulants

strongly considered who are identified as :

👉high probablity of PE

👉moderate clinical suspicion for acute PE and the diagnostic evaluation is expected to take longer than 4 hours .

👉low clinical suspicion for acute PE and the diagnostic evaluation is expected to take longer than 24 hours

👉🏾IVC filter is considered if there's Contraindications to anticoagulants, after confirmation of dx.

⁦3️⃣⁩⁦Investigation

👉ECG : to rule out Acute coronary syndrome .

👉X-Ray : to rule out pleural effusion and pneumothorax .

👉CT Pulmonary angiography: assess Rt ventricular dysfunction and clot burden .

👉TTE: detect right sided cardiac thrombus or right heart dysfunction. And help in excluding acute coronary syndrome, aortic dissection, pericardial tamponade, pulmonary arterial hypertension and congestive heart failure.

👉lower extremity venous compression ultrasonograph CUS : detect DVT.

👉MDCT : if dx remain uncertain .

👉V/Q scan : if CT is Contraindicated.

👉🏾D-Dimer : in low and moderate probability.

👉🏾Troponin I : detect Myocardial necrosis .

👉🏾BNP : detect Rt ventricular dysfunction .

4️⃣ Thrombolytic therapy

👉Commonly used thrombolytics include streptokinase, urokinase, alteplase.

👉Indicated in massive and submassive PE .

5️⃣Embolectomy

👉Embolectomy can be approached via catheters or surgically.

👉strongly considered when a patient’s

presentation is severe enough to warrant thrombolysis but thrombolytic therapy

either has failed or is contraindicated.