A 60-year old obese male with a history of chronic smoking since childhood presents in ICU with pelvic fracture due to fall from height. On the 4th day of the ICU stay, he developed sudden tachypnoea, fall in SpO2 and hypotension. On 2D echo, there was a dilation of right ventricle and tricuspid regurgitation. What would be the next immediate step?
Correct Answer: Systemic thrombolysis
Description: Ans. D . Systemic thrombolysis (Ref: Harrison 19/e p1631-1637, 18/e p2170-2177; Sabiston 19/e p295-297; Schwartz 9/e p787-789: Bailey 26/e p917)Clinical picture mentioned in this question is highly suggestive of deep venous thrombosis leading to pulmonary embolism. As the patient has developed pulmonary embolism with hypotension and tachypnea, the immediate step would be Systemic thrombolysis."Anticoagulation is the foundation for successful treatment of DVT and PE. Immediately effective anticoagulation is initiated with a parenteral drug: unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), or fondaparinux. One should use a direct thrombin inhibitors (argatroban, lepirudin, or bivalirudin) in patients with proven or suspected heparin-induced thrombocytopenia. Parenteral agents are continued as a transition or "bridge " to stable, long-term anticoagulation with a vitamin K antagonist (exclusively warfarin in the United States). Warfarin requires 5-7 days to achieve a therapeutic effect. During that period, one should overlap the parenteral and oral agents."- Harrison 18/e p2173"Successful fibrinolytic therapy rapidly reverses right heart failure and may result in a lower rate of death and recurrent PE by (1) dissolving much of the anatomically obstructing pulmonary arterial thrombus, (2) preventing the continued release of serotonin and other neurohumoral factors that exacerbate pulmonary hypertension, and (3) lysing much of the source of the thrombus in the pelvic or deep leg veins, thereby decreasing the likelihood of recurrent PE. The preferred fibrinolytic regimen is 100 mg of recombinant tissue plasminogen activator (tPA) administered as a continuous peripheral intravenous infusion over 2 hours. Patients appear to respond to fibrinolysis for up to 14 days after the PE has occurred. Contraindications to fibrinolysis include intracranial disease, recent surgery, and trauma. The only FDA-approved indication for PE fibrinolysis is massive PE."- Harrison 18/e p2173.Pulmonary EmbolismRisk factors for pulmonary embolism are the risk factors for thrombi formation within venous circulation.Calf venous thrombosis: Low risk for embolismThrombosis of larger veins: High risk for embolism (due to loosely attached thrombus to venous wall)MC site for DVT: Calf veinsQMC source for pulmonary emboli: Proximal vein of lower extremityQ (femoro-popliteal and iliac vein)Pulmonary EmbolismRisk Factors for Pulmonary Thromboembolism* Age (increasing age)Q* Obesity Q* Immobility (bed rest >4days)Q* PregnancyQ and PuerperiumQ* High dose estrogen therapyQ* Surgery (trauma (especially of pelvis, hip or lower limb)Q* Malignancy (especially pelvis, abdominal, metastatic)* Heart failure/Recent MIQ* Nephrotic syndromeQ* Inflammatory bowel diseaseQ* PolycythemiaQ* PNHQ or Lupus anticoagulant* Behcet's syndromeQ* HomocystinuriaQ* Paralysis of lower limb* Varicose veins, InfectionClinical features:Symptoms: Dyspnea chest pain, hemoptysis and coughSigns: Tachypnea (MC)Q. fever, unilateral leg swelling, wheeze, pleural friction rubAny patient with high likelihood of pulmonary embolism on clinical evaluation straightaway undergoes imaging tests, while a patient with low clinical likelihood should first undergo D-dimer test.Factors for Clinical Assessment of Pulmonary Embolism* Clinical signs and symptoms of DVTQ* An alternative diagnosis is less likely than pulmonary embolism* Heart rate >100/minQ* HemoptysisQ* Immobilization or previous surgery in 4 weeksQ* Previous DVT/PEQ* MalignancyQ (on treatment, treatment in past 6 months) ECG Changes in Pulmonary Embolism(Sinus tachycardia: MC and non-specific finding on ECGQ)Features of Acute Right Heart StrainHighly predictive of PE* Acute right axis deviation* P pulmonale* Right bundle branch block* Inverted T waves* ST segment change* S1Q3T3Q: Seen in < 12% patients- S wave in lead I- Q wave in lead III- Inverted T wave in lead III- S wave in lead I, II. and III (S1S2S3)Diagnosis:D-dimer: Excellent screening test for the diagnosis of PEQ.Best investigation in clinical suspicion of PE: Multidetector CTQ.Eung scanning is now a 2nd line diagnostic test for PE.Pulmonary angiography: Gold standard for diagnosis of PEQ (but expensive and cumbersome)Treatment:Anticoagulation is the foundation for successful treatment of DVT and PE. Immediately effective anticoagulation is initiated with a parenteral drug, unfractionated heparin (UFH)Q.The only FDA-approved indication for PE fibrinolysis is massive PEQ.Pulmonary embolectomy: The risk of intracranial hemorrhage with fibrinolysis has prompted a renaissance of surgical embolectomy.
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