- See: - deep venous thrombosis / respiratory failure
- Discussion:
- time range of diagnosis of PE following discharge: 14-68 days (JR Lieberman et al);
- ref: Early pulmonary embolism after injury: A different clinical entity?
- in the report by Lawton RL and Morrey BF (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;
- consider 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: an analysis of genetic factors.
- Clinical Findings:
- hypoxia: 63 % of patients will have a pulse ox level less than 90%;
- arterial blood gas
- acute respiratory alkalosis;
- pO2 < 80mm on Rm Air;
- elevated (A-a)O2 gradient;
- troponin may be elevated;
- EKG changes:
- references:
- Continuous pulse oximetry and the diagnosis of pulmonary embolism in critically ill trauma patients.
- Clinical presentation of pulmonary embolus after total joint arthroplasty: do size and location of embolus matter?
- Diagnostic Studies:
- CT scan:
- ref: A Pilot Study of Computed Tomography–Detected Asymptomatic Pulmonary Filling Defects After Hip and Knee Arthroplasties
- VQ scan: reasonable if the patient can cooperate with the ventilation part of the test (ie not too SOB or disoriented);
- ref: Clinical validity of a normal perfusion lung scan in patients with suspected pulmonary embolism.
- Management:
- anticoagulation:
- used if no contraindications exist;
- treatment modalities for DVT:
- lovenox: (lovenox dosing calculator)
- heparin
- in the report by Lawton RL and Morrey BF (1999), the authors advise that patients who demonstrate clinical signs of a PE should have dx
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;
- IV Heparain is started to keep PTT > 2.0 times normal.
- need to be aware of heparin induced thrombocytopenia.
- references: - The use of heparin in patients in whom a pulmonary embolism is suspected after total hip arthroplasty.
- warfarin
- patient must be anticoaguated with Heparin before Coumadin is started in order to avoid skin necrosis.
- begin heparin or lovenox: 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;
- refs:
- Optimum duration of anticoagulation for deep-vein thrombosis and pulmonary embolism. Research Committee of the British Thoracic Society.
- Apixaban: (oral factor Xa inhibitor) may be given 2.5 mg or 5 mg PO qd.
- Apixaban for Extended Treatment of Venous Thromboembolism
- vena cava filter:
- indicated if there are contraindications to anticoagulation:
- 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 should prevent fatal emboli in about 2-4% of patients undergoing major acetabular fixation (as compared to 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.
- Greenfield filter prophylaxis of pulmonary embolism in patients undergoing surgery for acetabular fracture.
- thrombolytic therapy: (urokinase, streptokinase)
- thrombolysis is indicated in the case of patients with pulmonary embolism who have arterial hypotension or are in shock;
- need for thrombolytic treatments depends on presence and severity of hemodynamic instability due to right ventricular failure;
- selected patients with evidence of right ventricular dysfunction and a low risk of bleeding may benefit from early thrombolysis;
- complications: 13% cumulative rate of major bleeding and a 1.8% rate of intracranial or fatal hemorrhage
- references:
- Recent advances in the diagnosis and lytic therapy of pulmonary embolism.
- 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 clinical course of pulmonary embolism.
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.