Updated: 5/27/2019

Pulmonary Thromboembolism

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Introduction
  • Pulmonary embolism as seen by CT. The white arrows highlight the filling defects of IV contrast.Defined as occlusion of a pulmonary artery from embolization of a thrombus from a distal site
    • size of embolism determines proximity of occlusion to pulmonary trunk
      • Saddle embolus
        • large clot that occludes central pulmonary arteries
    • most commonly due to a thromboembolism from the deep veins of the leg
      • highest number originate from femoral vein
  • Risk factors
    • Virchow's triad
      • stasis
        • immobility
        • CHF
        • obesity
        • surgery
      • hypercoagulability
        • pregnancy
        • OCP
        • protein C/S deficiency
        • factor V Leiden
        • severe burns
        • cancer
      • endothelial damage
        • exposed collagen stimulates clotting cascade
          • trauma
          • fracture
          • previous DVT
Presentation
  • Dyspnea and tachycardia common presenting findings
  • May see hypoxemia on pulse oximetry and ABG
    • ABG often shows ↓ PO2↓ PCO2↑ A-a gradient 
  • Pleuritic chest pain
  • Sudden death
    • acute right heart failure from rapid increase in pulmonary artery pressure
    • more common with saddle embolism
  • Pleural friction rub
  • Fever
    • if pulmonary infarct
  • Deep vein thrombosis
    • Homans' sign
      • dorsiflexion of foot leads to tender calf muscle
      • not present in the majority of cases (not sensitive or specific)
    • erythematous, swollen, warm, lower extremity
 
Imaging
  • Chest CT with angiography
    • test of choice in most circumstances
    • visualize filling defect in pulmonary artery
  • V/Q radionuclide scan
    • ↓ pulmonary perfusion without decreased ventilation to given area
    • used when patient cannot tolerate CT contrast (renal failure, pregnancy)
    • requires a normal chest xray to be useful
  • pulmonary angiogram
    • gold-standard confirmatory test
    • rarely used
Studies
  • Labs
    • serum D-dimers 
      • result of clot degradation
      • only useful if low pretest probability (Wells criteria)
        • high sensitivity but low specificity
Treatment
  • Pharmacologic
    • anticoagulation 
      • heparin or low-molecular weight heparin (LMWH)
      • warfarin
        • begin for long term anticoagulation
    • thrombolysis
      • in cases of hemodynamic compromise
  • Operative
    • inferior vena cava filter
      • indicatied if anticoagulation is contraindicated or if patient develops a PE while on  anticoagulants
    • thrombectomy
      • in cases of hemodynamic compromise and contraindication to thrombolytic therapy
  • Prevention
    • Subcutaneous heparin or LMWH most effective for immobile patients or patients at high risk
    • early ambulation as able
    • Sequential compression devices when pharmacologic prophylaxis is contraindicated
Complications
  • Pulmonary infarction
    • most cases do not result in infarction due to large degree of collateral circulation in the lungs
    • occur when patient has a reduction in pulmonary blood flow
      • secondary to decreased cardiac output or obstructive lung disease
  • Death
    • Due to right ventricular failure
 

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Questions (6)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.PL.20) A 73-year-old female is hospitalized following a pelvic fracture. She undergoes surgical repair without complication. Four days into her hospital stay, she develops acute dyspnea and chest pain accompanied by oxyhemoglobin desaturation. Which of the following arterial blood gas values is the patient most likely to have? (normal values: pH 7.35 - 7.45, PaO2 80 - 100 mm Hg, PaCO2 35-45 mm Hg, HCO3 22-26) Review Topic

QID: 100823
1

pH 7.5, PaO2 60, PaCO2 30, HCO3 22

43%

(3/7)

2

pH 7.3, PaO2 60, PaCO2 30, HCO3 20

0%

(0/7)

3

pH 7.5, PaO2 60, PaCO2 50, HCO3 28

29%

(2/7)

4

pH 7.3, PaO2 60, PaCO2 50, HCO3 24

14%

(1/7)

5

pH 7.4, PaO2 60, PaCO2 40, HCO3 24

0%

(0/7)

M1

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PREFERRED RESPONSE 1

(M1.PL.4) Four days after undergoing an elective total hip replacement, a 65-year-old woman develops a DVT that embolizes to the lung. Along with tachypnea, tachycardia, and cough, the patient would most likely present with a PaO2 of what? Review Topic

QID: 100807
1

120 mmHg

0%

(0/7)

2

110 mmHg

0%

(0/7)

3

100 mmHg

29%

(2/7)

4

85 mmHg

0%

(0/7)

5

60 mmHg

71%

(5/7)

M1

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PREFERRED RESPONSE 5
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