Pulmonology Book

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Pulmonary EmbolismAka: Pulmonary Embolus, Lung Infarction

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  1. See Also
    1. Deep Vein Thrombosis (DVT)
    2. Pulmonary Embolism Diagnosis
  2. Epidemiology
    1. Incidence in United States
      1. Total Cases: 650,000 per year
      2. Deaths per year: 200,000 per year
      3. Deaths in first hour: 11%
    2. Mortality increases with age
      1. Age 40 years: 2.5%
      2. Age over 65 years: 40%
    3. Mortality increases if diagnosis missed
      1. Diagnosed in Emergency Department: 5% Mortality
      2. Missed Diagnosis: 30% Mortality
      3. Missed diagnosis in 50 to 70%
  3. Risk Factors
    1. Pulmonary Embolism Risk Factors
  4. Differential Diagnosis
    1. See Chest Pain Causes
    2. See Dyspnea Causes
    3. See Leg Pain Causes
    4. Baker's Cyst (Pseudo-thrombosis)
  5. Symptoms
    1. Classic Triad
      1. Chest Pain (80-90%)
        1. Pleuritic Chest Pain (74%)
        2. Non-Pleuritic Chest Pain (14%)
      2. Cough (40-53%)
      3. Hemoptysis (13-20%)
    2. Dyspnea (75-85%)
    3. Apprehension or anxiety (50-65%)
    4. Syncope (5-13%)
    5. Diaphoresis (27-36%)
  6. Signs
    1. Tachypnea (80-90%)
      1. Respiratory Rate over 16 (92%)
      2. Respiratory Rate over 20 (70%)
    2. Rales (50-58%)
    3. Tachycardia (40-50%)
    4. Fever (40%)
      1. Temperature usually 37.8 to 38.5 C
      2. Temperature rarely over 38.5 C (102.5)
    5. Gallup rhythm (34%)
    6. Phlebitis (32%)
    7. Edema (24%)
    8. Cardiac murmur (23%)
    9. Adventitious breath sounds
    10. Cyanosis (19%)
    11. Circulatory collapse (8%)
    12. Lower extremity swelling, tight cords, or tenderness
    13. Homan's Sign not helpful
  7. Complications
    1. Acute Cor Pulmonale (Pulmonary Hypertension)
    2. Massive Pulmonary Embolism
      1. Systemic hypotension and shock
      2. Right Heart Failure
  8. Diagnosis
    1. See Pulmonary Embolism Diagnosis
  9. Labs
    1. D-Dimer (ELISA Test - do not use latex agglutination)
      1. Only useful in Low PE Probability patient
      2. Negative Predictive Value 99.5% if Low PE Probability
      3. Wells (2001) Ann Intern Med 135:98
    2. Arterial Blood Gas (normal in 15% of PE patients)
      1. Normal ABG does not rule out PE
      2. Arterial pO2 low (Hypoxia)
        1. Most patients: 60-70 mmHg
        2. Twenty percent of patients: >80mmHg
        3. Five percent of patients: >90mmHg in 5%
      3. Respiratory Alkalosis
        1. Arterial pCO2 decreased in 95% of patients
      4. A-a Gradient
        1. Sensitivity: 90%
        2. Sensitivity with low arterial pCO2: 98%
  10. Diagnostic Tests: Electrocardiogram
    1. See Electrocardiogram in PE
  11. Radiology: Chest XRay
    1. Nonspecific Chest XRay changes in 85%
      1. Elevated hemidiaphragm (50%)
      2. Hampton's Hump
        1. Pleural based infiltrate pointed towards hilum
      3. Westmark Sign
        1. Dilated proximal vessels with a distal cutoff
      4. Pleural Effusion
      5. Atelectasis
    2. Rules out other Dyspnea Causes
      1. Pneumothorax
      2. Pneumomediastinum
      3. Aortic Dissection
      4. Pneumonia
    3. Normal Chest XRay in Acute Dyspnea and Hypoxemia
      1. Suggests Pulmonary embolism if no Wheezing
  12. Radiology
    1. Lower Extremity Doppler (Impedance Plethysmography)
    2. VQ Scan
    3. Pulmonary Angiography
    4. Transesophageal Echo
    5. CT Scan (Helical and Ultrafast): Not currently 1st line
      1. Efficacy
        1. 86% Sensitive for central emboli
        2. 63% Sensitive for subsegmental vessels
      2. Disadvantages
        1. VQ Scan is preferred
        2. Difficult to use if patient severely dyspneic
          1. Patient must hold breath for 15 to 30 seconds
        3. Misses peripheral emboli
    6. Chest MRI (No current use in PE evaluation)
      1. Efficacy
        1. 90% sensitive for proximal emboli
      2. Disadvantages
        1. 10% unable to get adequate study
      3. Indications
        1. Angiography contraindicated
        2. Pregnancy
  13. Management
    1. See Pulmonary Embolism Management
  14. Prognosis
    1. Brain Natriuretic Peptide (BNP) may predict prognosis
      1. BNP <90 pg/ml associated with benign course
      2. Kucher (2003) Circulation 107:2545

Pulmonary Embolism (C0034065)

Definition (MSH)Blocking of the PULMONARY ARTERY or one of its branches by an EMBOLUS.
Definition (NCI)The closure of the pulmonary artery or one of its branches by an embolus, sometimes associated with infarction of the lung.
Definition (NCI)The closure of the pulmonary artery or one of its branches by an embolus, sometimes associated with infarction of the lung.
ConceptsDisease or Syndrome (T047)
ICD9415.1
MSHD011655
BasqueBIRIKA EMBOLIA
DanishLungeemboli
DutchLong embolie/long infarct
EnglishEMBOLISM PULM, EMBOLISM PULMONARY, EMBOLISMS PULM, Embolus - pulmonary, EMBOLUS PULMONARY, PE - Pulmonary embolism, PULM EMBOLISM, PULM EMBOLISMS, Pulmonary artery embolism, pulmonary embolism, Pulmonary Embolisms, PULMONARY EMBOLUS
FinnishKEUHKOEMBOLIA
FrenchEmbolie pulmonaire
GermanLungenembolie/Lungeninfarkt
Hebrewtasxif reati
Hungarianembolia pulmonum
ItalianEmbolia polmonare
NorwegianLUNGEEMBOLI
PortugueseEmbolia pulmonar
Spanishembolia pulmonar, embolismo pulmonar, tromboembolismo pulmonar
SwedishLUNGEMBOLI
Parent ConceptsVenous Thrombosis (C0042487), Vascular abnormalities (C0241657), Arterial and Arteriolar Disorders (C0549520), Respiratory System Disorders, General, Functional and NEC (C0549576), circulatory system (C0497231), Diagnosis/Diseases Component (C0497531), Embolism (C0013922), Lung diseases (C0024115), Pulmonary circulation disease NOS (C0178272), Pulmonary artery finding (C0428843), Trunk arterial embolus (C0729946)
SourcesCOSTAR, CSP, CST, DXP, ICPC, ICPCBAQ, ICPCDAN, ICPCDUT, ICPCFIN, ICPCFRE, ICPCGER, ICPCHEB, ICPCHUN, ICPCITA, ICPCNOR, ICPCPOR, ICPCSPA, ICPCSWE, LCH, MEDLINEPLUS, MSH, MTH, MTHICD9, NCI, NDFRT, OMIM, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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