Pulmonary Embolism

Warning:

• Diagnosis evoked by context and promoting the clinic.

• Any suspected pulmonary embolism (PE) requires a transfer to hospital for confirmation and initiation of anticoagulation.

• Do not ignore the imperfect forms, particularly without obvious phlebitis

Clinic:

The context is thrombophlebitis (see), but not always!

functional signs: pain, sudden or increasing dyspnea, cough, hemoptysis.

Physical signs: fever, tachypnea, tachycardia, phlebitis associated (but sometimes absent clinically), cyanosis, pulmonary burst of B2, éjectionnel pulmonary systolic murmur, or tricuspid regurgitation.

misleading forms: OAP, bronchospasm, angina, syncope, worsening of dyspnea usual.

severe (acute right heart failure): hepatalgia, IVD signs of respiratory distress with shock, intense cyanosis.

Additional tests:

– ECG (interest of a previous ECG) +++ sinus tachycardia or atrial rhythm disorders, signs of right atrial enlargement, right axis deviation, appearance S1Q3, incomplete right ++ block, ischemia subepicardial anteroseptal; However, inconsistent ++ changes in crude forms.

– Echocardiography Doppler: indirect signs (dilation of the right cavities, paradoxical septum, and tricuspid insufficiency signs PAH), sometimes direct signs of a thrombus in the right cavities (against-indicating pulmonary arteriography) or the trunk of the AP, assessment of cardiac output. The review oesophageally (if any) can sometimes visualize the proximal thrombus.

– Chest X-ray in bed ++ climbing a dome, atelectasis in bands, filling pleural cul-de-sac, located hypovascularisation, amputation of a pulmonary artery, cardiomegaly right; however, may be normal ++.

– Blood Gas: non-specific hypoxemia hypocapnia, witnesses of gravity.

– Determination of D-dimer: sensitive (excellent negative predictive value) but not specific.

– Lung scintigraphy ventilation / perfusion: normal, it eliminates the diagnosis +++; abnormal, there are many false positives.

– MR angiography and pulmonary angiography scanner: not traumatic, very efficient for diagnostics.

Moreover, looking for signs of DVT +++ +++ clinical and laboratory.

To behave:

– Evoking the outset diagnosis.

– Assess the severity of the clinical picture.

– Possible Oxygen.

– Refer the patient in hospital medical transport (ambulance).

Order No. 1: pulmonary embolism small or medium importance

– Strict rest in bed

– Oxygen therapy and monitoring SaO2 continuously.

– Heparin Syringe: bolus of 100 IU / kg followed IVD 500 IU / kg / day to adapt aPTT (2 to 3 times the control)

or simpler: INNOHEP [tinzaparin sodium] 175 IU / kg / day in a single subcutaneous injection daily (monitoring of anti-Xa activity is indicated in cases of renal failure in the subject aged: it must be less than 1.5 anti-Xa IU / ml)

– Early relay by PREVISCAN [fluindione] 1 tablet daily, then adjust according to (INR between 2 and 3):

– Down ++ venous contention,

– Authorized up from the correct hypocoagulability obtained.

– Duration of anticoagulation: 6 months, or for life in case of recurrence risk factor (antiphospholipid syndrome, coagulation factor deficiencies …).

Ordinance No. 2: severe pulmonary embolism with shock

– In ICU

– In the absence of indication-cons, thrombolysis with Actilyse [alteplase] 100 mg IV over 2 hours followed by Heparin Syringe 400-600 IU / kg / day

– The power inotropespositives drugs

– Whether against-indications to thrombolysis, emergency surgery.