Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ 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 ... Your Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.