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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Otherwise unexplained dyspnea, tachypnea, or chest pain

  • Clinical, ECG, or echocardiographic evidence of acute cor pulmonale

  • Positive chest CT angiography scan with contrast

  • High-probability ventilation-perfusion lung scan or high-probability perfusion lung scan with a normal chest radiograph

  • Positive venous ultrasound for thrombus in the legs, with a convincing clinical history and a suggestive lung scan

  • Diagnostic pulmonary angiogram

GENERAL CONSIDERATIONS

  • Pulmonary embolism is seen in:

    • – Immobilized patients, such as after surgery

    • – Patients with congestive heart failure, malignancies, pelvic trauma, and deep venous thrombosis

  • In the absence of surgery or trauma, pulmonary embolism often is due to a hypercoagulable state, which may be genetic or secondary to cancer or hormone therapy

  • The most common genetic causes of venous thromboembolism are factor V Leiden and mutations of the prothrombin gene

  • Venous thromboembolism is a major problem for women because it is associated with oral contraceptives, hormone replacement therapy, and pregnancy

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Dyspnea

  • Chest pain

  • Syncope

  • Symptoms of deep venous thrombosis

  • Hemoptysis

PHYSICAL EXAM FINDINGS

  • Tachycardia

  • Hypotension

  • Cyanosis

  • Elevated jugular venous pressure

  • Right ventricular lift

  • Right-sided S3

  • Tachypnea

  • Evidence of deep venous thrombosis

DIFFERENTIAL DIAGNOSIS

  • Pneumonia

  • Myocardial infarction

  • Pulmonary disorder with pleurisy

  • Respiratory distress secondary to pulmonary edema, asthma, or pleural effusion

  • Early sepsis

  • Psychogenic hyperventilation

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Arterial blood gases: may be abnormal

  • Plasma D-dimer: elevated

  • Troponin: may be elevated

  • Brain natriuretic peptide: may be elevated

ELECTROCARDIOGRAPHY

  • Acute cor pulmonale: S1, Q3, T3 pattern

  • New incomplete right bundle branch block

  • Evidence of right ventricular hypertrophy with strain

  • P pulmonale

IMAGING STUDIES

  • Chest x-ray: a peripheral pie-shaped infiltrate is unusual but diagnostic

  • Lung scan for ventilation-perfusion defect

  • CT angiogram of chest with contrast: can show arterial filling defects that are diagnostic

  • CT of the legs: can also demonstrate deep venous thrombosis and can be combined with CT of the chest

  • Venous ultrasonography: can demonstrate deep venous thrombosis

  • Echocardiography may show:

    • – Thrombi in the main pulmonary arteries

    • – Dilated hypokinetic basal right ventricle with normal apical contraction and normal left ventricle

    • – Interventricular septal flattening in systole (deviation to the left)

    • – Elevated pulmonary pressures detected by Doppler

    • – Evidence of reduced cardiac output

    • – Right ventricular hypertrophy

    • – Patent foramen ovale

DIAGNOSTIC PROCEDURES

  • Transesophageal echocardiography can be used in critically ill patients to directly visualize thrombi in the main pulmonary arteries (especially useful in patients with pulseless electrical activity)

  • Pulmonary angiography is usually reserved for therapeutic purposes, such as suction catheter embolectomy

  • Pulmonary angioscopy is reserved for diagnosing ...

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