Case conference

1
???????Case conference

• ????? ??
• ????? ??
• 2002.9.3

2
Personal information

• Name ?X?
• Age 84 y/o
• Sex F
• Sent by Family, at 8/20 1150 AM
• Cons Alert
• Vital sign T38, PR70, RR16, BP 186/73
• Triage 2

3
Chief complaint

• According to the family unable to wake up the
  pt.

4
Present illness

• AM 500 waking up.
• AM 800 eating breakfast, then took unknown
  antihypertension drugs.
• AM 900 went to bed.
• AM 1100 her son couldnt wake her up. So they
  left for hospital. Patient regained her
  consciousness just before the arrival.
• Chest tightness and palpitation complained.

5
Past history

• HTN (), with unknown drugs control.
• DM (-)
• Colon ca s/p OP 10 years ago, with post OP
  chemotherapy and radiotherapy for 1 year. Bed
  ridden for 2-3 years.
• Denied CAD, arrhythmia, and dyspnea on exertion.

6
Physical examination

• Cons alert, oriented
• Neck supple
• Conjunctiva not anemic
• Anicteric sclera.
• HS RHB, no murmur
• BS mild basal crackle
• Limbs no pitting edema
• NE Grossly normal

7
What is your impression?

• ACS ?
• Pnuemonia ?
• Syncope ?
• TIA?
• Others?

8
Duty doctors impression

• Syncope episode with bradycardia
• r/o AMI

9
Plan (1)

• Triage II
• CXR(AP)
• EKG
• CBC/DC, PLT, PT/PTT
• Panel I, CK/CK-MB/TnI, Ca
• N/S 60 ml/hr

10
CXR (AP)

• Please turn your heads left

11
Laboratory findings (1)

• WBC 4.4 k/ul (SL 6523)
• Hb 13.3 g/dl, Hct 40.5, Plt 132k/l
• PT 10.95/10.2, PTT 31.05/31.3, INR 1.17
• Biochem
• Na/K 146/4.4
• Glu 105
• GOT 16
• BUN/Cr 19/0.7
• CPK/CKMB 35/20
• TnI lt 0.1
• Ca 8.7

12
Plan (2)

• Arrange cardiac echo
• CXR, left lateral
• 340 pm check CK/CKMB
• At 1721 CPK/CKMB 56/28

13
Cardiac echo

• LVEDD 38 mm (36-52), EF 70
• Normal chamber size, septal hypertrophy
• Normal wall motion
• Valve np
• No thrombus, no pericardial effusion
• Tricuspid flow moderate TR, TR-PG 44 mmHg
• No RVEDD data

14
What is your next step?

• Pulmonary hypertension is impressed.
• Any possible cause?

15
Plan (3)

• 430 pm D-dimer
• 1801 D-dimer 0.8
• U/A
• UA RBC 1-2, WBC 3-5, Epi 0-1, Bac
• Lung perfusion scan
• 8/21 EKG, CK/CKMB/TnI
• 0114 CPK/CKMB 45/18, TnI 0.0

16
Tc99m MMA lung perfusion scan

• There are segmental defects in the ant. basal and
  lat. basal segment of the right lung, and lingual
  superior segment of the left lung. It is our
  understanding that the pt has a suspicious
  embolism. The scintigraphic finding suggest high
  probability of pulmonary embolism.

17
Plan (4)

• 1250 PM Clexane 60 mg sc, st and bid x 1 day
• Admission to CV

18
Admission

• Coumadin 1 qd and st x 2 day, then ½ qd
• Clexance 60 mg sl, q12h and st
• 8/22 TL-201 myocardial perfusion scan inferior
  wall ischemia, lung congestion.
• 8/25 hold coumadin
• 8/27 coumadin ½ qod
• Arrange cardiac cath, but pt refused and AAD

19
Discharge

• Dx pulmonary embolism
• Drugs
• Coumadin ½ qod
• Sennoside 1 qN

20
Syncope

• Definition
• Transient loss of consciousness with an inability
  to maintain postural tone that resolves
  spontaneously without medical or surgical
  intervention
• ?Cardiac output
• mechanical outflow obstruction, pump failure,
  hemodynamically significant arrhythmias, or
  conduction defects
• ?Systemic vascular resistance
• vasomotor instability, autonomic failure, or
  vasodepressor/vasovagal response. Arterial
  pressure decreases with all causes of hypovolemia
  
• CNS event
• Hemorrhage or seizure, also can present as
  syncope

21
Secondary pulmonary artery hypertension (SPAH)

• Hypoxic vasoconstriction
• chronic obstructive pulmonary disease
• high-altitude disorders
• hypoventilation disorders (eg, obstructive sleep
  apnea).
• Obliteration of pulmonary vasculature
• systemic scleroderma or CREST
• Acute/Chronic pulmonary embolism
• HIV and toxin

22
Secondary pulmonary artery hypertension (SPAH)

• Obliteration of pulmonary vasculature
• left-to-right intracardiac shunts
• Left atrial hypertension
• left ventricular dysfunction
• mitral valvular disease
• constrictive pericarditis
• aortic stenosis
• cardiomyopathy

23
Venous thromboembolism (VTE)

• Deep vein thrombosis (DVT)
• Pulmonary thromboembolism (PTE)
• 3rd most common cause of death in the US
• 780,000 cases, 400,000 missed, 100,000
  preventable death annually in the US
• Autopsy 70 of the PTE cases missed Dx.
• Superficial vein thrombosis (SVT)
• Chronic venous insufficiency (CVI)

24
How to diagnose pulmonary embolism?

• Symptoms and signs
• Risk factors
• X-ray
• EKG
• D-dimer
• Echocardiography
• V/Q scan
• Spiral CT
• Pulmonary angiography
• Autopsy

25
Symptoms
26
Signs
27
Risk factors

• Hx of DVT 5-30x new VTE
• Varicose veins 2x develop DVT
• Hematologic abnormalities
• Protein C, Protein S has DVT or PTE before 35y
• Familial antithrombin III deficiency has PTE
  before 50y
• Polycythemia and thrombocytosis
• Risk increase linearly with hematocrit
• Platelet gt 1M/ul, increased likelihood of
  bleeding problems
• Surgery
• Catheter-associated thrombosis
• Anesthesia
• Immobility
• 1 week of bed rest, DVT rate15 in ward, 30 in
  ICU
• Autoimmune disease and immunodeficiency

28
Risk factors

• Cancer
• Colon cancer and ovarian cancer
• Chemotherapy
• Inflammatory bowel disease
• Stroke and neurotrauma
• ½ develop acute DVT in 5 days.
• Coronary artery disease
• Pregnancy and puerperium
• PTE is the most nontraumatic cause of maternal
  death during pregnancy and the postparteum
  period.
• Exogenous estrogens
• Risk of VTE 4x
• Blood cell surface antigens
• Non-O type blood 2-4x risk of VTE

29
Most common findings in ECG

• Tachycardia
• Non-specific ST-T changes
• Right side heart strains
• P pulmonale (Tall peak P in lead II)
• RAD
• RBBB
• Af
• S1Q3T3
• 20 of proven PTE will have any of the classic
  findings

30
Pretest probability
31
Pretest probability

• 7.8 of patients with scores of less than or
  equal to 4 had PE but if the D-dimer was negative
  in these patients the rate of PE was only 2.2
• The combination of a score lt or 4.0 by our
  simple clinical prediction rule and a negative
  SimpliRED D-Dimer result may safely exclude PE in
  a large proportion of patients with suspected PE.
• Wells PS, Anderson DR, Rodger M, Ginsberg JS,
  Kearon C, Gent M, et al. Derivation of a simple
  clinical model to categorize patients probability
  of pulmonary embolism increasing the models
  utility with the SimpliRED d-dimer. Thromb
  Haemost. 200083416-20. PMID 10744147

32
Echocardiograpy

• Right side heart strain Strong predictor of
  death
• Immediate fibrinolysis
• Ratio of right-to-left ventricular end-diastolic
  diameters correlates with angiographic indices of
  the severity of the obstruction
• Assessing the severity of proven PTE, not for
  primary diagnosis of PTE
• Because these indirect signs can be seen in RV
  infarction or other causes of pulmonary
  hypertension.
• TEE very poor sensitivity, high specificity

33
V/Q scan

• Perfusion scan neither sensitive nor specific
  for PTE
• Ventilation scan increases the specificity but
  not the sensitivity of abnormal perfusion scans
• Mismatch
• Large ventilation defect small perfusion
  defect air space disease
• Small venttilation defect large perfusion
  defect more consistent with PTE
• Safe for pregnant pt. (1/10 of max. permissible
  fetal GI exposure dose)

34
PIOPED V/Q scan criteria (1)

• a. High Probability (in the absence of conditions
  known to
• mimic pulmonary embolism)
• ? 2 large mismatched segmental perfusion defects
  or the arithmetic equivalent in moderate or large
  and moderate defects. (A large segmental defect,
  gt75 of a segment, equals 1 segmental equivalent
  a moderate defect, 25 75 of a segment, equals
  0.5 segmental equivalents a small defect, lt25
  of a segment, is not counted.)
• Two large mismatched segmental perfusion defects,
  or the arithmetic equivalent, are borderline for
  high probability. Individual readers may
  correctly interpret individual images with this
  pattern as high probability. In general, it is
  recommended that more than this degree of
  mismatch be present for the high probability
  category.

35
PIOPED V/Q scan criteria (2)

• b. Intermediate Probability
• One moderate to two large mismatched perfusion
  defects or the arithmetic equivalent in moderate
  or large and moderate defects.
• Single-matched ventilation-perfusion defect with
  clear chest radiograph. Very extensive matched
  defects can be categorized as low probability.
• Single ventilation-perfusion matches are
  borderline for low probability and thus should
  be categorized as intermediate in most
  circumstances by most readers, although
  individual readers may correctly interpret
  individual scintigrams with this pattern as low
  probability.
• Difficult to categorize as low or high or not
  described as low or high.

36
PIOPED V/Q scan criteria (3)

• c. Low Probability
• Nonsegmental perfusion defects (e.g.
  cardiomegaly, enlarged aorta, enlarged hila,
  elevated diaphragm).
• Any perfusion defect with a substantially larger
  chest radiographic abnormality.
• Perfusion defects matched by ventilation
  abnormality (see IV.H.1.b.2) provided that there
  are a) clear chest radiograph and b) some areas
  of normal perfusion in the lungs.
• Any number of small perfusion defects with a
  normal chest radiograph.
• d. Normal
• No perfusion defects or perfusion exactly
  outlines the shape of the lungs seen on the chest
  radiograph (note that hilar and aortic
  impressions may be seen and the chest radiograph
  and/or ventilation study may be abnormal).

37
Problems of V/Q scan

• Interobserver disagreement (25, 30 in the
  PIOPED trial for intermediate and low probability
  group)
• Most often nondiagnostic ¾ of pt do not have
  clear result, these pt should undergo bilateral
  legs duplex study.
• The likelihood pattern increased with time due to
  loss of surfactant and secondary air space
  abnormalities.

38
Spiral CT scan

• Pros
• lt 20 sec for pulmonary embolism scan
• Consider central or segmental emboli Sen and Spe
  90
• Provide alternative diagnosis. (2/3 pt referred
  for V/Q scan do not have PTE)
• Cost-effective
• Cons
• Relative contraindications contrast material
  allergy and renal failure
• Subsegmental emboli interobserver agreement is
  only 66. It is dangerous to lost the pt with
  limited cardiopulmonary reserve small
  peripheral clots.
• Better use the D-dimer first to rule out some pt
  first.

39
Spiral CT scan

• J michael Holber MD et al. Role of spiral
  computed tomography in the diagnosis of pulmonary
  embolism in the emrgency department. Volume 33.
  Number 5. May 1999, Annals of Emergency Medicine
• Dividing pt into 2 groups.
• The first group has no chronic cardiopulmonary
  disease.
• For those have intermediate-probability V/Q
  scans, spiral CT proved a correct Dx for 80 of
  them.
• If still normal or indeterminate with high
  clinical suspicion ?Angiography
• Low clinical suspicion spiral CT may provide
  other possible diagnosis
• Second group has chronic CP disease.
• If no DVT sign, spiral CT is their first choice
• With DVT sign / normal or indeterminate CT
  finding ? Doppler
• Both CT and Doppler (-) repeat 5 days later for
  Doppler, or receive pul. Angiography, or
  additional test for other Dx.

40
Pulmonary angiography

• Pros
• No other modality has equal spatial resolution
  gold standard
• Wedge angiography can show 1.5 mm emboli.
• Interobserver agreement only 81
• No special risk for pregnant pt.
• Cons
• Mortality 0.3, Major complication 1-3
• However, compared with undiagnosed PTE, the
  mortality is low enough to justify its continued
  use.
• lt ½ pts with moderate of indeterminated V/Q scan
  underwent angiography.

41
Treatment

• Anticoagulation
• Heparin
• 100-150 u/kg, keep 18 u/kg/hr
• Keep aPTT gt 1.5x
• Reduced mortality from gt 30 to lt 10
• LMWH
• Wafarin
• keep INR gt 2.5 or 3.0
• At least use anticoagulants gt 6 months.

42
Clexane (Enoxaparin sodium)

• Fractionated LMWH
• 1 mg/kg sc q12hr or 1.5 mg/kg sc qd
• Checking aPTT has no utility. It is usually not
  prolonged even the pt is fully anticoagulated.
• Used widely in pregnancy, although clinical
  trials not yet available

43
Clexane (Enoxaparin sodium)

• Prevention of DVT after surgery, or bed-ridden
• Tx of established DVT /- PE
• Prevention of clotting in extracorporeal
  circulation during HD
• Acute tx of unstable angina and non-Q-wave
  myocardial infarction
• 1mg protamine sulfate can neutrolize 1 mg
  enoxaparin.

44
Fibrinolysis

• Immediate fibrinolysis is indicated for
• Hypotensive
• Massive PTE
• Syncope with persistent hemodynamic comporomise
• Significantly hypoxemic
• Other evidence of delepted cardiopulmonary
  reserves
• Fastest-acting agent preferred
• Alteplase, streptokinase (rare use), and
  urokinase (not available)

45
Conclusion

• What make you think of the diagnosis?
• Syncope
• Chest tightness and tenderness
• Atypical location
• No evidence of MI attack
• No infection sign, although feverish
• Risk factor bed ridden, colon ca.
• Pulmonary hypertension