Pulmonary Embolism (PE)

Pulmonary Embolism (PE)CLINICAL SIGNS:

* Difficult diagnosis because signs are not very sensitive and not very specific.

* acute dyspnea of polypnea type (70%), cough (40%).

* chest pain (60%) with or without hemoptysis (10%), tachycardia (30%), sometimes inaugural syncope (10%).

* fever between 37.5 ° and 38.5 ° C.

* the signs are frustrated in the elderly:

– think about dyspnea or malaise rather than chest pain.

– think of it as worsening of dyspnea in a patient with heart disease or COPD.

* clinical signs of severity:

– respiratory rate> 30 / min, cyanosis.

– lipothymia, agitation, torpor.

– signs of right ventricular failure:

 jugular turgor, hepato-jugular reflux, painful hepatomegaly.

Collapse <90 mmHg, tachycardia> 110 / min.

* look for signs of thrombophlebitis (20%).

DIFFERENTIAL DIAGNOSIS:

* other chest pain:

– IDM, aortic dissection, acute pericarditis, tamponade, acute pneumonitis, pneumothorax, digestive emergencies.

ETIOLOGY:

* Deep thrombophlebitis of the lower limbs.

* taking estrogen-progestins.

* post-operative or post-partum period.

* prolonged immobilization , plastered restraint.

* chronic respiratory failure, neoplasia.

* abnormalities of hemostasis.

DIAGNOSTIC TESTS:

* scope, SpO².

* ECG :

– to compare if possible with an earlier ECG.

– normal in minor to moderate forms.

– modifications in the more severe forms: right branch block, QRS deviation.

– if severe form: aspect S1Q3, disorders of the repolarization in precordial straight.

* chest x-ray :

– normal (25%).

– dome ascension, pulmonary arterial distention, minimal pleural effusion, flat or discoid atelectasis, focal hypovascularization, infarct condensation.

– Eliminate some differential diagnoses: pneumonitis, pneumothorax.

* if D-dimers made by the Elisa technique <500 μg / l: no pulmonary embolism (97%).

* standard biological assessment, hemostasis.

* blood gas: hypoxemia-hypocapnia inconstant, SpO2 <60% if severe form.

* then as soon as possible:

– Doppler ultrasound in emergency but not always available.

– echocardiography: useful for eliminating other diagnoses.

– scintigraphy: if normal, one can conclude that it is not a pulmonary embolism.

– spiral CT angiography that signs the diagnosis.

TREATMENT:

* venous route: G5%, mask oxygen therapy: 6 to 8 l / min.

Venous restraint if associated phlebitis.

* hospitalization.

* heparinotherapy :

– Heparin loading dose: 100 IU / kg IV direct.

 then Heparin continuous: 400-500 IU / kg / day.

Or Innohep: 175 IU anti-Xa / kg in one subcutaneous injection per day (0.1 ml / 10 kg) -0.1 ml.

* if collapse: Plasmion, 500 ml and Dobutrex, 5 μg / kg / min.

* if respiratory distress, convulsions, circulatory arrest:

– Intubation and assisted ventilation after possible anesthesia (Hypnovel: 0.05 mg / kg IV + Fentanyl: 1 μg / kg IV).

* hospitalization, in intensive care if signs of gravity.

* fibrinolysis for severe or poorly tolerated pulmonary embolism:

– 15000 IU / kg bolus (10 min) for urokinase and 0.6 mg / kg bolus for r-tPA, combined with heparin, alteplase: 100 mg / 2 hours.

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Editor-in-chief of the Medical Actu website; general practitioner graduated from the Faculty of Medicine of Algiers in 2005 currently practicing as a liberal.

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