- See:
-
deep venous thrombosis:
-
respiratory Failure:
- Discussion:
- time range of diagnosis of PE following discharge:
14-68 days (JR Lieberman et al);
-
hypercoagulable conditions:
- pulmonary embolism from specific conditions:
-
PE arising from trauma, pelvic fractures, and extremity fractures:
- risk of pulmonary embolism following acetabular fractures is about 4-7%;
-
PE in hip frx and surgery:
-
PE following THR:
-
PE following TKR:
-
PE arising from trauma and fractures:
- references:
-
Correlation of Thrombophilia and Hypofibrinolysis with Pulmonary Embolism Following Total Hip Arthroplasty.
- Clinical Findings:
-
EKG changes:
- acute
respiratory alkalosis;
- pO2 < 80mm on Rm Air;
- elevated (A-a)O2 gradient;
- references:
-
Continuous pulse oximetry and the diagnosis of pulmonary embolism in critically ill trauma patients.
- Management:
-
confirm the diagnosis:
- VQ scan: is the study of choice if the patient can cooperate with the ventilation part of the test (ie not too SOB or disoriented);
- pulmonary arteriogram:
- ref:
Clinical validity of a normal perfusion lung scan in patients with suspected pulmonary embolism.
-
vena cava filter:
- indicated if there are contraindications to anticoagulation:
- if there are contraindicajtions and PE is documented, consider IVC interruption;
- in multi-trauma patients consider prophylactic placement of a vena cava filter;
- decrease in incidence of pulmonary embolism can be expected;
- filters should remove 98% of emboli;
- filters can be expected to prevent fatal emboli in about 2-4% of patients undergoing major acetabular
fixation (as compared to patients who recieve other forms of DVT prophylaxis);
- long term patency rate of IVC is about 94% at 1-2 years;
- sudden severe leg edema following filter insertion may indicate the occurance of a large embolus;
- criteria for filter placement (2/5 criteria must be met);
- age greater than 55 yrs;
- ISS greater than 16;
- complex pelvic fracture;
- long bone and pelvic fracture;
- fracture (pelvic / lower extremity) requiring prolonged bed rest;
- references:
-
Prophylactic vena cava filter insertion in severely injured trauma patients: indications and preliminary results.
- Prophylactic Vena Cava Filter Insertion in Selected High Risk Orthopaedic Trauma Patients.
FB Rogers et al.
J. Orthop Trauma. 1997. Vol 11. No 4. p 267-272.
- Greenfield filter prophylaxis of pulmonary embolism in patients undergoing surgery for acetabular fracture.
LX Webb et al.
J. Orthop. Trauma. Vol 6(2) 1992 p 139-145.
-
anticoagulation:
- used if no contraindications exist;
- in the report by RL Lawtom and BF Morrey (JBJS Vol 81-A, No 8, Aug 1999), the authors advise that patients who demonstrate clinical signs of a PE
should have the diagnosis confirmed before starting empiric IV heparin;
- they noted at 47% complication rate in their patients (versus 20% in patients that did not receive heparin);
- they found no benefit to starting IV heparin prior to confirmation of the diagnosis;
- begin
heparin: plan to continue heparin for 7-10 days;
- plan to add
warfarin at day 3;
- d/c heparin after about 1 week;
- plan to continue warfarin for 2-6 months;
- ref:
Optimum duration of anticoagulation for deep-vein thrombosis and pulmonary embolism. Research Committee of the British Thoracic Society.
-
thrombolytic therapy:
-
Recent advances in the diagnosis and lytic therapy of PE.
-
Thrombolytic therapy for postoperative pulmonary embolism.
- References:
Clinical Cardiology: Diagnosis, Treatment, and Prevention of Pulmonary Embolism: Report of the WHO/International Society and Federation of Cardiology Task Force.
Original Contributions: A Prospective Investigation of Pulmonary Embolism in Women and Men.
The incidence of fatal pulmonary embolism after knee replacement with no prophylactic anticoagulation. [Review
The clinical course of pulmonary embolism.
Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin.
Collins R, Scrimgeour A, Yusef S, Peto R.
N Engl J Med.1988;318:1162-1173.
Thromboembolism following multiple trauma.
Autopsy-verified major pulmonary embolism after hip fracture.
Brief Report: Frequent Asymptomatic Pulmonary Embolism in Patients With Deep Venous Thrombosis.
The efficacy of sequential compression devices in multiple trauma patients with severe head injury.
Risk of pulmonary emboli in patients with pelvic fractures.
Brief Report: Frequent Asymptomatic Pulmonary Embolism in Patients With Deep Venous Thrombosis.
Mortality and fatal pulmonary embolism post primary total hip replacement: results from a region hip register.
D. Fender et al.
JBJS Vol 79-B. 1997. p 896-899.
Death and thromboembolic disease after total hip replacement: a series of 1162 cases with no routine chemical prophlaxis.
D. Warwick et al.
JBJS Vol 77-B. 1995. p 6-10.
Death rate from pulmonary embolism following joint replacement surgery.
D. Megrath et al.
Jour. Royal Coll Surg. Eninb. Vol 41. 1996. p 256.
