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Pulmonary embolism
Classification and external resources
ICD-10 I26.
ICD-9 415.1
DiseasesDB 10956
MedlinePlus 000132
eMedicine med/1958  emerg/490 radio/582
MeSH D011655

Pulmonary embolism (PE) is a blockage of the pulmonary artery (or one of its branches), usually occuring when a venous thrombus (blood clot from a vein), becomes dislodged from its site of formation and embolizes to the arterial blood supply of one of the lungs. The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The International Statistical Classification of Diseases and Related Health Problems 10th Revision ( ICD -10) is a coding of diseases and signs symptoms abnormal findings I00-I99 - Diseases of the Circulatory system (I00-I02 Acute rheumatic fever ( Rheumatic fever without mention of Heart The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. The Diseases Database is a free Website that provides information about the relationships between medical conditions Symptoms, and Medications. MedlinePlus, with the MedlinePlus Medical Encyclopedia, is a website network containing Health information from the world's largest medical Library eMedicine is an online clinical medical knowledge base that was founded in 1996 by Scott Plantz and Richard Lavely two medical doctors Medical Subject Headings ( MeSH) is a huge Controlled vocabulary (or metadata system for the purpose of indexing journal articles and books The pulmonary arteries carry Blood from the Heart to the Lungs. In the Circulatory system, a vein is a Blood vessel that carries Blood back toward the Heart (as opposed to Artery, a blood vessel A thrombus, or blood clot, is the final product of the Blood coagulation step in Hemostasis. In Medicine, an embolism occurs when an object (the embolus, plural emboli) migrates from one part of the Body (through circulation The pulmonary arteries carry Blood from the Heart to the Lungs. This process is termed thromboembolism.

Symptoms may include difficulty breathing, pain in the chest during breathing, and in more severe cases collapse, circulatory instability and sudden death. Dyspnea or dyspnoea (pronounced disp-nee-ah, IPA /dɪsp'niə/ from Latin dyspnoea, from Greek dyspnoia from Pain, in the sense of physical pain, is a typical sensory experience that may be described as the unpleasant awareness of a noxious stimulus or bodily harm In Medicine, chest pain is a Symptom of a number of serious conditions and is generally considered a Medical emergency. Collapse is a sudden and often unannounced loss of postural tone (going weak often but not necessarily accompanied by loss of consciousness. A cardiac arrest, also known as cardiorespiratory arrest, cardiopulmonary arrest or circulatory arrest, is the abrupt cessation of normal circulation of Treatment, usually, is with anticoagulant medication, such as heparin and warfarin, and rarely (in severe cases) with thrombolysis or surgery. An anticoagulant is a substance that prevents coagulation; that is it stops Blood from clotting Heparin, a highly-sulfated Glycosaminoglycan, is widely used as an injectable Anticoagulant and has the highest negative Charge density of any known Warfarin (also known under the brand names Coumadin, Jantoven, Marevan, and Waran) is an Anticoagulant. Thrombolysis is the breakdown ( lysis) of blood clots by pharmacological means In other, rarer forms of pulmonary embolism, material other than a blood clot is responsible; this may include fat or bone (usually in association with significant trauma), air (often when diving), clumped tumor cells, and amniotic fluid (affecting mothers during childbirth). Lipids are broadly defined as any fat- Soluble ( lipophilic) naturally-occurring Molecule, such as fats oils waxes cholesterol sterols fat-soluble Bones are rigid organs that form part of the Endoskeleton of Vertebrates They function to move support and protect the various organs of the body produce Temperature and layers The temperature of the Earth's atmosphere varies with altitude the mathematical relationship between temperature and altitude varies among five This article refers to underwater diving by humans For other uses of the term diving see Dive and Diving Underwater diving is See also Cancer A tumor or tumour is the name for a swelling or lesion formed by an abnormal growth of cells (termed neoplastic Amniotic fluid or liquor amnii is the nourishing and protecting liquid contained by the Amnion of a pregnant woman "Mom" "Mum" and "Mommy" redirect here Childbirth (also called labour, birth, partus or parturition) is the culmination of a Human Pregnancy or

Contents

Signs and symptoms

Symptoms of PE are sudden-onset dyspnea (shortness of breath), tachypnea (rapid breathing), chest pain of a "pleuritic" nature (worsened by breathing), cough, hemoptysis (coughing up blood), and may aid in the diagnosis. Dyspnea or dyspnoea (pronounced disp-nee-ah, IPA /dɪsp'niə/ from Latin dyspnoea, from Greek dyspnoia from Tachypnea (or "tachypnoea" ( Greek: "rapid breathing" is characterized by rapid breathing and is not identical with Hyperventilation - tachypnea In Medicine, chest pain is a Symptom of a number of serious conditions and is generally considered a Medical emergency. In Medicine, a cough ( Latin: tussis) is a sudden and often repetitively occurring defence Reflex which helps to clear the large breathing passages Hemoptysis or haemoptysis (see American and British spelling differences) is the expectoration ( Coughing up of Blood or of blood-stained More severe cases can include signs such as pleural rub, cyanosis (blue discoloration, usually of the lips and fingers), collapse, and circulatory instability. Cyanosis is a blue coloration of the Skin and mucous membranes due to the presence of deoxygenated Hemoglobin in Blood vessels near the skin surface Collapse is a sudden and often unannounced loss of postural tone (going weak often but not necessarily accompanied by loss of consciousness. About 15% of all cases of sudden death are attributable to PE. The term sudden cardiac death refers to Natural death from cardiac causes heralded by abrupt loss of Consciousness within one hour of the onset of acute symptoms

Diagnosis

The diagnosis of PE is based primarily on validated clinical criteria combined with selective testing because the typical clinical presentation (shortness of breath, chest pain) cannot be definitively differentiated from other causes of chest pain and shortness of breath. Dyspnea or dyspnoea (pronounced disp-nee-ah, IPA /dɪsp'niə/ from Latin dyspnoea, from Greek dyspnoia from In Medicine, chest pain is a Symptom of a number of serious conditions and is generally considered a Medical emergency.

The decision to do medical imaging is usually based on clinical grounds, i. e. the medical history, symptoms and findings on physical examination. The medical history or Anamnesis of a Patient is information gained by a Physician or other healthcare professional by asking specific questions Physical examination or clinical examination is the process by which a Health care provider investigates the body of a Patient for signs

The most commonly used method to predict clinical probability, the Wells score, is clinical prediction rule, whose use is complicated by multiple versions being available. A clinical prediction rule is type of medical research study in which researchers try to identify the best combination of Medical sign, Symptoms, and other findings In 1995, Wells et al initially developed a prediction rule (based on a literature search) to predict the likelihood of PE, based on clinical criteria. Year 1995 ( MCMXCV) was a Common year starting on Sunday. Events of 1995 [1] The prediction rule was revised in 1998[2] This prediction rule was further revised when simplified during a validation by Wells et al in 2000. [3] In the 2000 publication, Wells proposed two different scoring systems using cutoffs of 2 or 4 with the same prediction rule. [3] In 2001, Wells published results using the more conservative cutoff of 2 to create three categories. [4] An additional version, the "modified extended version", using the more recent cutoff of 2 but including findings from Wells's initial studies[1][2] were proposed. [5] Most recently, a further study reverted to Wells's earlier use of a cutoff of 4 points[3] to create only two categories. [6]

There are additional prediction rules for PE, such as the Geneva rule. More importantly, the use of any rule is associated with reduction in recurrent thromboembolism. [7]

The Wells score:[8]

Traditional interpretation[3][4][9]

Alternate interpretation[3][6]

Blood tests

In low/moderate suspicion of PE, a normal D-dimer level (shown in a blood test) is enough to exclude the possibility of thrombotic PE. D-dimer is a Fibrin degradation product, a small protein fragment present in the blood after a blood clot is degraded by Fibrinolysis. A blood test is a laboratory analysis performed on a Blood sample that is usually extracted from a Vein in the arm using a needle, or via [11]

When a PE is being suspected, a number of blood tests are done, in order to exclude important secondary causes of PE. A blood test is a laboratory analysis performed on a Blood sample that is usually extracted from a Vein in the arm using a needle, or via This includes a full blood count, clotting status (PT, APTT, TT), and some screening tests (erythrocyte sedimentation rate, renal function, liver enzymes, electrolytes). A complete blood count ( CBC) also known as full blood count ( FBC) or full blood exam ( FBE) or blood panel, is Coagulation is a complex process by which Blood forms Clots It is an important part of Hemostasis (the cessation of blood loss from a damaged vessel whereby The prothrombin time ( PT) and its derived measures of prothrombin ratio ( PR) and international normalized ratio ( INR) are measures The partial thromboplastin time' (PTT or activated partial thromboplastin time ( aPTT or APTT) is a performance indicator measuring the efficacy of both the "intrinsic" The Thrombin Clotting Time (TCT also known as the Thrombin Time (TT is a coagulation assay which is usually performed in order to detect for the therapeutic level of the Anticoagulant The erythrocyte sedimentation rate (ESR also called a sedimentation rate, sed rate, or Biernacki Reaction, is the rate at which Red blood cells Renal function, in Nephrology, is an indication of the state of the Kidney and its role in Renal physiology. Liver function tests (LFTs or LFs which include liver enzymes, are groups of Clinical biochemistry laboratory blood assays designed to give information about the An electrolyte is any substance containing free Ions that behaves as an electrically conductive medium If one of these is abnormal, further investigations might be warranted.

Medical imaging

The gold standard for diagnosing pulmonary embolism (PE) is pulmonary angiography. In Medicine, a gold standard test or criterion standard test is a Diagnostic test or benchmark that is regarded as definitive Pulmonary angiography (or pulmonary arteriography) is a cardiological medical procedure Pulmonary angiography is used less often due to wider acceptance of CT scans, which are non-invasive.

Non-invasive imaging

CT pulmonary angiography (CTPA) is a pulmonary angiogram obtained using computed tomography (CT) with radiocontrast rather than right heart catheterization. CT pulmonary angiogram (CTPA is a medical diagnostic test that employs Computed tomography to obtain an image of the pulmonary arteries. Pulmonary angiography (or pulmonary arteriography) is a cardiological medical procedure Computed tomography (CT is a Medical imaging method employing Tomography. Contrast medium Radiocontrast agents (also simply contrast agents or contrast materials) are compounds used to improve the visibility of internal bodily structures Its advantages are clinical equivalence, its non-invasive nature, its greater availability to patients, and the possibility of identifying other lung disorders from the differential diagnosis in case there is no pulmonary embolism. A differential diagnosis (sometimes abbreviated DDx, ddx Assessing the accuracy of CT pulmonary angiography is hindered by the rapid changes in the number of rows of detectors available in multidetector CT (MDCT) machines. [12] A study with a mixture of 4 slice and 16 slice scanners reported a sensitivity of 83% and a specificity of 96%. This study noted that additional testing is necessary when the clinical probability is inconsistent with the imaging results. [13] CTPA is non-inferior to VQ scanning, and identifies more emboli (without necessarily improving the outcome) compared to VQ scanning. [14]

Ventilation/perfusion scan (or V/Q scan or lung scintigraphy), which shows that some areas of the lung are being ventilated but not perfused with blood (due to obstruction by a clot). A ventilation/perfusion lung scan, also called a V/Q lung scan is a type of Medical imaging used to evaluate the circulation of air and blood within a patient's Lungs Nuclear medicine is a branch of Medicine and Medical imaging that uses the nuclear properties of matter in diagnosis and therapy In Respiratory physiology, ventilation (or ventilation rate) is the rate at which gas enters or leaves the Lung. In Physiology, perfusion is the process of nutritive delivery of Arterial Blood to a Capillary bed in the Biological tissue. This type of examination is used less often because of the more widespread availability of CT technology, however, it may be useful in patients who have an allergy to iodinated contrast or in pregnancy due to lower radiation exposure than CT. Iodinated contrast is a form of intravenous Radiocontrast (radiographic dye containing Iodine, which enhances the visibility of vascular structures and organs during Pregnancy ( Latin graviditas) is the carrying of one or more offspring known as a Fetus or Embryo, inside the Uterus of a Female [15]

Low probability diagnostic tests/non-diagnostic tests

Tests that are frequently done that are not sensitive for PE, but can be diagnostic.

Electrocardiogram findings

An electrocardiogram (ECG) is routinely done on patients with chest pain to quickly diagnose myocardial infarctions (heart attacks). Myocardial infarction ( MI or AMI for acute myocardial infarction) also known as a heart attack, occurs when the blood supply An ECG may show signs of right heart strain or acute cor pulmonale in cases of large PEs - the classic signs are a large S wave in lead I, a large Q wave in lead III and an inverted T wave in lead III ("S1Q3T3"). Cor pulmonale is a change in structure and function of the Right ventricle of the heart as a result of a respiratory disorder [17] This is occasionally (up to 20%) present, but may also occur in other acute lung conditions and has therefore limited diagnostic value. The most commonly seen signs in the ECG is sinus tachycardia, right axis deviation and right bundle branch block. [18]

Echocardiography findings

In massive and submassive PE, dysfunction of the right side of the heart can be seen on echocardiography, an indication that the pulmonary artery is severely obstructed and the heart is unable to match the pressure. An echocardiogram is a Sonography of the Heart. Also known as a cardiac ultrasound it uses standard ultrasound techniques to image two-dimensional slices of The pulmonary arteries carry Blood from the Heart to the Lungs. Some studies (see below) suggest that this finding may be an indication for thrombolysis. Thrombolysis is the breakdown ( lysis) of blood clots by pharmacological means Not every patient with a (suspected) pulmonary embolism requires an echocardiogram, but elevations in cardiac troponins or brain natriuretic peptide may indicate heart strain and warrant an echocardiogram. Troponin is a complex of three regulatory proteins that is integral to Muscle contraction in skeletal and Cardiac muscle, but not Smooth muscle Brain natriuretic peptide (BNP also known as B-type natriuretic peptide (also BNP or GC-B, is a 32 amino acid polypeptide secreted by the ventricles [19]

The specific appearance of the right ventricle on echocardiography is referred to as the McConnell sign. This is the finding of akinesia of the mid-free wall but normal motion of the apex. This phenomenon has a 77% sensitivity and a 94% specificity for the diagnosis of acute pulmonary embolism. [20]

Combining tests into algorithms

Recent recommendations for a diagnostic algorithm have been published by the PIOPED investigators; however, these recommendations do not reflect research using 64 slice MDCT. [10] These investigators recommended:

Treatment

In most cases, anticoagulant therapy is the mainstay of treatment. Acutely, supportive treatments, such as oxygen or analgesia, are often required. Oxygen therapy is the administration of Oxygen as a therapeutic modality

Massive PE causing hemodynamic instability (marked decreased oxygen saturation, tachycardia and/or hypotension) is an indication for thrombolysis, the enzymatic destruction of the clot with medication. Oxygen saturation is a relative measure of the amount of Oxygen that is Dissolved or carried in a given medium In Physiology and Medicine, hypotension refers to an abnormally low Blood pressure. Thrombolysis is the breakdown ( lysis) of blood clots by pharmacological means Some advocate its use also if right ventricular dysfunction can be demonstrated on echocardiography. An echocardiogram is a Sonography of the Heart. Also known as a cardiac ultrasound it uses standard ultrasound techniques to image two-dimensional slices of [21]

Anticoagulation

Main article: anticoagulant

In most cases, anticoagulant therapy is the mainstay of treatment. An anticoagulant is a substance that prevents coagulation; that is it stops Blood from clotting An anticoagulant is a substance that prevents coagulation; that is it stops Blood from clotting Heparin, low molecular weight heparins (such as enoxaparin and dalteparin), or fondaparinux is administered initially, while warfarin therapy is commenced (this may take several days, usually while the patient is in hospital). Heparin, a highly-sulfated Glycosaminoglycan, is widely used as an injectable Anticoagulant and has the highest negative Charge density of any known In Medicine, low-molecular-weight heparin ( LMWH) is a class of Medication used as an Anticoagulant in diseases that feature Thrombosis Enoxaparin is a Low molecular weight heparin manufactured by Sanofi-Aventis. Dalteparin is a Low molecular weight heparin. It is marketed as Fragmin by Pfizer Inc. Fondaparinux (Arixtra is an Anticoagulant medication As shown in the box to the right fondaparinux is a synthetic pentasaccharide Warfarin (also known under the brand names Coumadin, Jantoven, Marevan, and Waran) is an Anticoagulant. Warfarin therapy often requires frequent dose adjustment and monitoring of the INR. The prothrombin time ( PT) and its derived measures of prothrombin ratio ( PR) and international normalized ratio ( INR) are measures In PE, INRs between 2. 0 and 3. 0 are generally considered ideal. If another episode of PE occurs under warfarin treatment, the INR window may be increased to e. g. 2. 5-3. 5 (unless there are contraindications) or anticoagulation may be changed to a different anticoagulant e. g. low molecular weight heparin. In Medicine, low-molecular-weight heparin ( LMWH) is a class of Medication used as an Anticoagulant in diseases that feature Thrombosis In patients with an underlying malignancy, therapy with a course of low molecular weight heparin may be favored over warfarin based on the results of the CLOT trial. In Medicine, low-molecular-weight heparin ( LMWH) is a class of Medication used as an Anticoagulant in diseases that feature Thrombosis [22] Similarly, pregnant women are often maintained on low molecular weight heparin to avoid the known teratogenic effects of warfarin, especially in the early stages of pregnancy. Teratology stems from the Greek ( Genitive) meaning monster, or marvel and, meaning word, speech.

People are usually admitted to hospital in the early stages of treatment, and tend to remain under inpatient care until INR has reached therapeutic levels. Increasingly, low-risk cases are managed on an outpatient basis in a fashion already common in the treatment of DVT. [23]

Warfarin therapy is usually continued for 3-6 months, or "lifelong" if there have been previous DVTs or PEs, or none of the usual risk factors is present. An abnormal D-dimer level at the end of treatment might signal the need for continued treatment among patients with a first unprovoked pulmonary embolus. D-dimer is a Fibrin degradation product, a small protein fragment present in the blood after a blood clot is degraded by Fibrinolysis. [24]

Used inferior vena cava filter, presented with a British twenty pence coin for scale.
Used inferior vena cava filter, presented with a British twenty pence coin for scale.

Inferior vena cava filter

Main article: inferior vena cava filter

If anticoagulant therapy is contraindicated and/or ineffective an inferior vena cava filter may be implanted. An inferior vena cava filter, also IVC filter a type of vascular filter is a Medical device that is implanted into the Inferior vena cava to prevent In Medicine, a contraindication (pronounced as contra-indication is a condition or factor that increases the Risks involved in using a particular drug, An inferior vena cava filter, also IVC filter a type of vascular filter is a Medical device that is implanted into the Inferior vena cava to prevent [25]

Thrombolysis

Main article: Thrombolysis

Thrombolysis can be given for severe PEs when surgery is not immediately available or possible (e. Thrombolysis is the breakdown ( lysis) of blood clots by pharmacological means Thrombolysis is the breakdown ( lysis) of blood clots by pharmacological means g. periarrest or during cardiac arrest). The only trial that addressed this issue had 8 patients; the four receiving thrombolysis survived, while the four who received only heparin died. [26] The use of thrombolysis in moderate PEs is still debatable. The aim of the therapy is to dissolve the clot, but there is an attendant risk of bleeding or stroke. A stroke is the rapidly developing loss of brain functions due to a disturbance in the blood vessels supplying blood to the brain [27]

Surgical management

Surgical management of acute pulmonary embolism (pulmonary thrombectomy) is uncommon and has largely been abandoned because of poor long-term outcomes. In Thoracic surgery, a pulmonary thrombectomy, is an Emergency procedure that removes clotted Blood ( Thrombus) from the pulmonary However, recently, it has gone through a resurgence with the revision of the surgical technique and is thought to benefit selected patients. [28]

Chronic pulmonary embolism leading to pulmonary hypertension (known as chronic thromboembolic hypertension) is treated with a surgical procedure known as a pulmonary thromboendarterectomy. In Medicine, pulmonary hypertension (PH is an increase in blood pressure in the Pulmonary artery, Pulmonary vein, or pulmonary capillaries together known In Thoracic surgery, a pulmonary thromboendarterectomy, PTE, is an operation that removes organized clotted Blood ( Thrombus

Prognosis

Mortality from untreated PE is said to be 26%. This figure comes from a trial published in 1960 by Barrit and Jordan,[29] which compared anticoagulation against placebo for the management of PE. Year 1960 ( MCMLX) was a Leap year starting on Friday (link will display full calendar of the Gregorian calendar. Barritt and Jordan performed their study in the Bristol Royal Infirmary in 1957. The Bristol Royal Infirmary, also known as the BRI, is a large Teaching hospital situated in the centre of Bristol, England This study is the only placebo controlled trial ever to examine the place of anticoagulants in the treatment of PE, the results of which were so convincing that the trial has never been repeated as to do so would be considered unethical. That said, the reported mortality rate of 26% in the placebo group is probably an overstatement, given that the technology of the day may have detected only severe PEs.

Prognosis depends on the amount of lung that is affected and on the co-existence of other medical conditions; chronic embolisation to the lung can lead to pulmonary hypertension. In Medicine, pulmonary hypertension (PH is an increase in blood pressure in the Pulmonary artery, Pulmonary vein, or pulmonary capillaries together known There is controversy over whether or not small subsegmental PEs need to be treated at all[30] and some evidence exists that patients with subsegmental PEs may do well without treatment. [31][13]

Predicting mortality

The PESI and Geneva prediction rules can estimate mortality and so may guide selection of patients who can be considered for outpatient therapy. [32]

Evaluation for underlying causes for recurrence

After a first PE, the search for secondary causes is usually brief. Only when a second PE occurs, and especially when this happens while still under anticoagulant therapy, a further search for underlying conditions is undertaken. An anticoagulant is a substance that prevents coagulation; that is it stops Blood from clotting This will include testing ("thrombophilia screen") for Factor V Leiden mutation, antiphospholipid antibodies, protein C and S and antithrombin levels, and later prothrombin mutation, MTHFR mutation, Factor VIII concentration and rarer inherited coagulation abnormalities. Coagulation is a complex process by which Blood forms Clots It is an important part of Hemostasis (the cessation of blood loss from a damaged vessel whereby

Epidemiology

Risk factors

The most common sources of embolism are proximal leg deep venous thrombosis (DVTs) or pelvic vein thromboses. In fields of Anatomy, anatomical terms of location are descriptive terms to help identify relative positions or directions within a species In Medicine, deep vein thrombosis (also known as deep-vein thrombosis or deep venous thrombosis and usually abbreviated as DVT) is the formation Any risk factor for DVT also increases the risk that the venous clot will dislodge and migrate to the lung circulation, which happens in up to 15% of all DVTs. The conditions are generally regarded as a continuum termed venous thromboembolism (VTE). Thrombosis is the formation of a blood Clot ( Thrombus) inside a Blood vessel, obstructing the flow of Blood through the Circulatory

The development of thrombosis is classically due to a group of causes named Virchow's triad (alterations in blood flow, factors in the vessel wall and factors affecting the properties of the blood). Virchow's triad encompasses the three broad categories of factors that are thought to contribute to Thrombosis. Often, more than one risk factor is present.

References

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External links

Dictionary

pulmonary embolism

-noun

  1. (pathology) The embolism or obstruction of a pulmonary artery, usually by a detached blood clot from a leg or pelvic vein, which causes a stoppage of blood into the lungs; symptoms include shortness of breath, chest pain, fainting, and sometimes death.
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