Signs And Symptoms Of Pulmonary Embolism

Describe the clinical features and management of pulmonary embolism.
Or
Write short note on pulmonary embolism.

Or
Enumerate etiology, clinical features, investigations,complications and management of pulmonary embolism

Answer. Pulmonary embolism is the most common and fatal form of venous thromboembolism in which there is occlusion of pulmonary arterial tree by thromboemboli.

Etiology pulmonary embolism

1. Thrombotic:

1. Deep vein thrombosis
2. Congestive heart failure
3. Right­sided endocarditis
4. Atrial firillation.

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2. Non-thrombotic:

1. Fat embolism
2. Amniotic flid embolism: Spontaneous delivery and cesarean section
3. Tumor embolism: Choriocarcinoma
4. Parasitic embolism: Schistosomiasis
5. Air embolism: Pulmonary barotraumas generally in the sea divers.

Clinical Features pulmonary embolism

In acute massive embolism, i.e. acute cor pulmonale

1. Symptoms are of presence of acute dyspnea, tachypnea,tachycardia, hemoptysis and chest pain.
2. Signs are increase in the jugular venous pressure, presence of central cyanosis, Loud P2 and narrow splittng of P2,an ejection systolic murmur in P2 area, right ventricular hypertrophy, signs of shock,

In small- or medium-sized pulmonary vessels embolization

1. Symptoms are hemoptysis, pleuritic pain and wheeze which is the triad of pulmonary infarct.
2. Signs are of pleural effusion i.e. reduced or absent chest wall movement and expansion of chest on the side involved, activity of extrarespiratory muscles is absent, position of trachea and mediastenum is shifted to opposite side, percussion note is stony dull on the side of involvement, vocal fremitus is reduced or absent on the side involved, breath sounds are absent or diminished over the area involved.

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In multiple microembolization, i.e. chronic cor pulmonale

1. Symptoms are of presence of dyspnea, weakness, fatigue and syncope.
2. Signs are increase in the jugular venous pressure, presence of cyanosis, edema, hepatomegaly, presence of loud P2 with the ejection systolic murmur in P2 area, presence of narrow splittng of P2, presence of parasternal heave and right ventricular atrophy.

Diagnosis pulmonary embolism

It is in the patients who had suspicion for underlying cause for emboli formation, development of pulmonary sign and symptoms as well as cardiovascular involvement, presence of thrombophlebitis in deep leg veins, prolonged bed rest, immobilization, cardiac irregularity in form of atrial firillation should be considered while keeping in mind clinical picture of precordial pain, breathlessness and tachycardia in patient who had recently gone for major surgery. Examination of veins is mandatory in the patients who are at high risk for development of deep vein thrombosis.
These features along with investigatory features form the diagnosis. Following are the investigations:

Investigations pulmonary embolism

1. Blood examination: If pulmonary infarct is present, there can be leucocytosis or raised ESR.
2. Chest X-ray: In massive pulmonary embolism, there is presence of diffse infitrates in the lung with increased bronchovascular markings.
   If medium size vessels are involved, there will be triangular pleuropulmonary opacity in peripheral lung filds, there can also be pleural effsion present.
3. Arterial blood gas analysis: Presence of hypoxemia and hypocapnia.
4. D-dimer: It is a fibrin degradation product release in circulation in pulmonary embolism.
   Presence of high levels of D­dimer is suggestive of an embolism while presence of low D­dimer exclude pulmonary embolism.
5. Echocardiography: It shows the right ventricular dilatation and presence of clot in it.
6. Spiral CT scan: CT of chest along with the IV contrast diagnose the pulmonary embolism.
   It effctively diagnose the large and central pulmonary embolism.
   Newer scanners can also detect peripherally present emboli.
7. Pulmonary angiography: It demonstrates the site of obstruction of all sized blood vessels.

Complications pulmonary embolism

1. The foremost complication for pulmonary embolism is pulmonary hypertension.
2. Right­sided heart failure
3. Peripheral segmental infarctions.

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Management pulmonary embolism

1. In patient of massive embolism

1. If patient is in state of shock or collapse:

1. Vasopressors such as dopamine or dobutamine are to be given.
2. Administer oxygen to the patient.
3. Correct acidosis
4. If there is failure of an initial resuscitation or there is hypotension or right ventricular dysfunction,primary therapy should be administered,i.e. dissociation of clot by thrombolysis or embolectomy.

2. If acute event is survived by the patient,

1. Streptokinase 2.5–5 lac unit IV > in dextrose or saline is given for 30 min followed by 1 lac IV for 24 hours.
2. Recombinant tissue plasminogen activator tPA, i.e. Alteplase 100mg for 2 hours is a good alternative to thrombolytic therapy.

3. Anti coagulation therapy is an initial and immediate treatment of choice.

1. Loading dose of 80–150 units/kg is given which is followed by 15 to 18 units/kg/hr as continuous infusion.
2. Warfarin should be added to heparin and is continued for 5 days.
3. After 5 days taper the heparin and administer warferin for 6 weeks to 6 months.
4. Monitor anticoagulant therapy by PTT or INR ratio or bleeding time which should be 2–3 times than the control.

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4. In small embolisms

1. Analgesics, i.e. NSAIDs should be given to relieve the pain.
2. Anticoagulant is given to prevent further embolization.
3. Various preventive measures should be undertaken such as calf muscle exercise, elastic stockings, prolong immobilization at bed, respiration exercises should be done.