A common disorder and potentially deadly
Occurs in approximately 1% of all hospitalized patients and
accounts for around 5% of in-hospital deaths.
It is a common mode of death in patients with
stroke, malignancy and pregnancy.
Diagnosis is highly elusive.
Autopsy reports suggest it is commonly “missed” diagnosed
4. Presentation is often “atypical”.
Signs and symptoms are frequently vague and
Untreated mortality rate of 20% - 30%,
plummets to 5% with timely intervention.
A 48-year-old woman is brought to the emergency room
complaining of a sudden onset of dyspnea. She reports she
was standing in the kitchen making dinner, when she
suddenly felt as if she could not get enough air, her heart
started racing, and she became lightheaded and felt as if
she would faint.
On examination, she is tachypneic with a respiratory rate of
28 breaths per minute, oxygen saturations 84% on room
air, heart rate 124 bpm, and blood pressure 118/89 mm Hg.
She appears uncomfortable, diaphoretic, and frightened.
Her right leg is moderately swollen from mid-thigh to her
feet, and her thigh and calf are mildly tender to palpation.
Her chest x-ray is interpreted as normal.
6. Epidemiology & Pathophysiology
Thrombi commonly form in deep veins of calf and propagate
into the proximal veins of the leg from where they embolize.
80% of pulmonary emboli arise from the propagation of
proximal lower limb DVT
Remaining 20% arise from
Pregnancy related DVT
Upper extremity DVT
Air, fat and amniotic fluid embolism.
7. • THROMBOSIS:TRIGGERED BY
• 2.VESSEL WALL INFLAMMATION
• ALL CLINICAL RISK FACTORS FOR
DVT/PE HAVE THEIR BASIS IN ONE
OR MORE ELEMENTS OF THE TRIAD.
8. Vessel Injury
Recent major trauma
Prolonged bed rest
Recent cast or external fixator
Long-distance travel or long flight
9. Acquired Inherited
Factor V Leiden
Protein C deficiency
Protein S deficiency
12. Wells’ Score
Clinical symptoms of DVT
(leg swelling, pain with
Other diagnosis less likely
Heart rate >100 1.5
Immobilization (≥3 days)
or surgery in the previous
Previous DVT/PE 1.5
Moderate 2.0 to 6.0
Modified Wells criteria
PE likely >4.0
PE unlikely ≤4.0
13. P A T I E N T S W I T H H I G H O R I N T E R M E D I A T E
C L I N I C A L S U S P I C I O N O F P U L M O N A R Y
E M B O L I S M S H O U L D B E P U T O N
A N T I C O A G U L A T I O N
B E F O R E S T A R T I N G I N V E S T I G A T I O N S
Investigations & Diagnosis
RV free wall hypokinesia with sparing of apex (McConnell sign
Septal flattening/ leftward septal shift/Paradoxical septal motion
Assessment of pulmonary artery pressure
Right chamber emboli
Alternative diagnoses like pericardial effusion, pericardial
temponade, aortic dissection, LVF
TEE can identify central pulmonary embolism
Elevated in thrombosis, malignancy, pregnancy, MI,
sepsis, elderly and hospitalized patients
Useful when low clinical probability for PE
Levels <500ng/ml rule out PE where clinical
probability is low.
In high probability patients proceed to CTPA,
negative d-dimer can miss up to 15% of patients in
26. CT Pulmonary Angiography
First-line diagnostic test
Quick and non-invasive
Allows direct visualization of emboli
Provides alternative diagnoses like aortic dissection,
ACS, consolidation, pneumothorax
May miss small peripheral emboli
28. V/Q scan
Seldom used nowadays
Used when CTPA is contra-indicated
Gives high, intermediate or low probability for PE
depending upon perfusion defects.
Normal scan rules out PE.
May not be useful if pre-existing lung disease.
Symptoms Right Heart
Minor Asymptomatic No Stable Discharged with
Symptomatic No Stable Admitted in Ward
Sub-massive Symptomatic Yes Stable In ICU
Massive Symptomatic Yes Unstable ICU
Available as LMWH or Unfractionated Heparin
FDA approved dosing:
LMWH: 1 mg/kg B.D
Unfractionated: 80 units/kg (or 5000 U) bolus
then 18 units/kg/hr or 1300U/h
LMWH is preferred in pregnant patients
A synthetic pentasaccharide
Alternative to LMWH
5 mg OD (for body weight below 50 kg)
7.5 mg OD (for body weight b/w 50–100 kg)
10 mg OD (for body weight above 100 kg)
38. Warfarin (Coumadin)
Vit. K antagonist
Inhibits hepatic synthesis of factor II, VII, IX, X,
protein C & S.
Patient is anticoagulated with heparin before
initiating warfarin therapy because it causes
temporary hypercoagulable state in first 5 days of
Target INR is 2. 0– 3.0
Warfarin alternatives are rivaroxaban, apixaban,
dabigatran & endoxaban.
40. Thrombolytic Therapy
Documented massive PE with
Syncope with persistent hemodynamic compromise
100 mg IV over 2 hour
IV anticoagulation is started immediately after
Loading dose 250,000 IU then 100,000 IU per hour
for 24 hour.
Maximum three million units per 24 hour.
44. Other Treatment Options
Before thrombolytic therapy this was only therapy
for massive PE
Now it is performed when thrombolysis is
Carries a 40% operative mortality
Anticoagulation is contraindicated
Recurrent VTE despite anticoagulation
49. • INDICATIONS
• Contraindications to
• Failed anticoagulation
• Developed a complication due to
• Severe cardiopulmonary
compromise where the next PE will
50. C O N S I D E R E D W H E N P A T I E N T ' S
P R E S E N T A T I O N I S S E V E R E E N O U G H T O
W A R R A N T T H R O M B O L Y S I S ( E . G . ,
P E R S I S T E N T H Y P O T E N S I O N ) , B U T
T H R O M B O L Y S I S E I T H E R F A I L S O R I S
C O N T R A I N D I C A T E D .
51. Catheter embolectomy
pressurized saline through
the catheter's distal tip, which
macerates the emboli
52. Surgerical Embolectomy
Performed on cardiopulmonary bypass with clots
extracted from the opened PAs under direct visualization
Indicated only when
1.Systemic hypotension due to PE in a patient in whom
thrombolysis is contraindicated
Possible: echocardiographic evidence of an embolus trapped within a
patent foramen ovale, the right atrium, or the right ventricle
2.Limited to large medical centers because an experienced
surgeon and cardiopulmonary bypass are required
53. • S U D D E N C A R D I A C D E A T H
• O B S T R U C T I V E S H O C K
• A R R Y T H M I A S
• H Y P O X I A
• L U N G I N F A R C T I O N
54. Massive PE
occlusion of the pulmonary artery that exceeds 50%
of its cross-sectional area, resulting in progressive
Usually presenting with systolic blood pressure < 90
obstruction of the PA to this degree initiates a
cascade of physiologic events, which if not
interrupted early, ultimately results in cardiac arrest
and death in up to 70% of patients in the first hour
55. Medical treatment of Massive PE
High dose IV heparin
IV fluids (empiric 500 mL)
increased right ventricular (RV) wall stress can decrease the ratio
of RV oxygen supply to demand. (ischemia, deterioration of RV
function, and worse RV failure)
Vasopressors (no evidence for which one)
Norepinephrine, epinephrine, or dopamine usually first line
Thrombolytics (if no contraindications)
56. • IMMEDIATE MORTALITY IS HIGH IN
THOSE WITH RIGHT VENTRICULAR
DYSFUNCTION OR CARDIOGENIC
• ONCE ANTICOAGULATION IS STARTED,
THE RISK OF MORTALITY FALLS
• THE RISK OF RECURRENCE IS HIGHEST
IN THE FIRST 6–12 MONTHS AFTER
THE INITIAL EVENT.
57. • INITIAL RESUSCITATION IS KEY .
• EMPIRIC ANTICOAGULATION SHOULD BE
CONSIDERED WHEN THE DIAGNOSIS
CANNOT BE A MADE IN A TIMELY MANNER.
• ANTICOAGULATION SHOULD BE
PROMPTED WITH APPROPRIATE AGENT(S).
• IVF FILTER SHOULD BE CONSIDERED
WHEN ANTICOAGULATION IS NOT AN