Embolic disease

Characteristics

  1. Pulmonary thromboembolism is a complication of deep vein thrombosis.
  2. If untreated there is a 30% mortality. If treated the mortality falls to <5%.
  3. Highest cause of maternal mortality in pregnancy.
  4. Associated with malignancy, immobility, thrombotic haematological disorders.
  5. D-Dimer blood test is very sensitive, but not very specific.
  6. Treatment is aimed at preventing further emboli.
  7. Patients with recurrent emboli may require long-term, sometimes lifelong, warfarin.
  8. Rarely emboli may represent fat emboli (following extensive lower limb/pelvic trauma) or tumour emboli. Fat embolus is rare and a distinct phenomenon. Patients present with acute SOB/collapse and dramatic CXR changes (extensive bilateral air space opacification similar to ARDS – adult respiratory distress syndrome).

Clinical features

  1. SOB.
  2. Cough, haemoptysis.
  3. Pleuritic chest pain.
  4. Deep leg vein thrombus.
  5. Hypoxia.
  6. Hypotension, tachycardia.
  7. Pulmonary arterial hypertension with right heart strain and failure.
  8. Collapse.
  9. Sudden death.

Radiological features

  1. CXR – may be normal.
  2. Other radiographic features of pulmonary embolic disease include:

Fleischner’s sign – local widening of pulmonary artery due to distension from clot.

Hampton’s hump – segmental pleurally based wedge-shaped opacity representing a pulmonary infarct.

Westermark’s sign – peripheral wedge-shaped lucency due to focal lung oligaemia.

  1. Ventilation/perfusion scan – mismatched perfusion defects.
  2. CT scan (CTPA) – filling defects within the pulmonary arterial tree on contrast-enhanced imaging. There may also be mosaic perfusion with reduced vasculature in the lucent areas.
  3. Pulmonary angiography – filling defects.
  4. Echocardiography – dilated right atrium with right ventricular hypertrophy and pulmonary arterial hypertension.

Embolic disease

Differential diagnosis

  1. The clinical presentation and CXR features are often non-specific and a number of conditions may mimic embolic disease (e.g. pneumothorax, infection, asthma and lung neoplasms).

Management

  1. ABC.
  2. Oxygen.
  3. Anticoagulation if PE is confirmed.
  4. Extensive thromboemboli with hypotension and tachycardia may require treatment with thrombolysis.

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