Journal Meeting

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Journal Meeting

• Reporter R1. ???
• Director Dr. ???
• 92-03-03

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Emergency Department Management Of Pulmonary
Embolism

• Emergency Medicine Clinics Of North America
• Vol.19, Nov,2001

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Frameworks

• 1. Introductions
• 2. Natural history of pulmonary embolism
• 3. Risk stratification
• 4. Goals of therapy
• 5. Unfractionated heparin (UFH)
• 6. LMWH
• 7. Thrombolytic therapy
• 8. IVC filter
• 9. Transvenous catheter embolectomy
• 10.Surgical embolectomy

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Introduction (1)

• 1960s, anticoagulant therapy ? mainstay for PE
• 1970s, thrombolytic therapy began to use in PE (
  esp. presenting in shock)
• 1990s, focused on risk stratification, extension
  of indication for thrombolytic therapy, use of
  LMWH, newer mechanical methods of therapy, and
  surgical embolectomy

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Introduction (2)

• The differential diagnosis is important since the
  treatment for PE is contraindicated in some of
  these conditions, such as pericarditis and aortic
  dissection
• Greatest threat to patient with PE is failure to
  be diagnosed.
• Correct decision regarding therapy can be made
  only after a correct diagnosis

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Natural history of pulmonary embolism

• Clots fron veins in legs, pelvis, and arm
  ?embolize to the lung?pulmonary vascular
  obstruction release vasoactive agents? increase
  pulmonary resistance?right ventricular
  dysfunction(hypertension, ischemia, and
  hypokinesis)? inadequate C.O. and death

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Natural history of pulmonary embolism (2)

• Approximately 10 patients die within the first
  hour of PE ( diagnosis and therapy unfeasible)
• Survive within first hours and remain untreated,
  approximately 30 will die of PE, usually from
  recurrent embolism and right heart failure.
• changes in position of the clots or endogenous
  fibrinolysis ? favorable outcome?less mortality

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Risk Stratification

• Treatment must be tailored to the individual
  patient, a one-size-fits-all policy does not
  make pathophysiologic sense.
• Prognostic factors
• 1. Embolic load
• 2. Underlying cardiopulmonary reserve
• 3. Status of the right ventricle

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Risk Stratification (2)

• In a multicenter study (2500 Pt of PE)
• RV dysfunction is an independent predictor of
  mortality

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Goals of therapy

• 1. Immediate goals of therapy
• ?normalize pulm. vascular resistance
• ? reduce recurrent embolism
• 2. long term goals
• ? reduce the frequency of chronic
  pulmonary hypertension

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Unfractionated Heparin (NFH)

• For decades, unfractionated heparin ? cornerstone
  of therapy for PE
• Unless contraindicated, heparin is used in
  high-likelihood patients

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Unfractionated Heparin (2)

• Several points bear emphasis
• 1. UFH, IV customarily, can be SC
• 2. Adequate initial anticoagulation is
  important to reduce the likelihood of recurrent
  venous thromboembolism

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Unfractionated Heparin(3)

• Recommended dose of heparin
• Initial 80 IU/kg, iv, bolus
• Maintain 18 IU/kg/hr, infusion
• ( P/s once fully heparinization, a first dose of
  warfarin can be administered )

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Low molecular weight heparin

• Multiple studies have shown that LMWH are equal
  in efficacy to UFH in the treatment of venous
  thromboembolic disease
• Enoxaparin and tinzaparin FDA approved on Nov,
  2000

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Low molecular weight heparin(2)

• Venous thromboembolic disease? primary
  manifestation is DVT, with or without PE, can be
  treated as out-patient ( carefully selected
  patient hemodynamic stable and normal RV
  function)
• If primary manifestation is PE? out-patient
  therapy is not recommended
• Admitted Pt with PE ( LMWH is used)
• 1.shorten the length of stay
• 2.not costly than using UFH

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Thrombolytic Therapy

• Advantages of thrombolytic therapy
• 1. Rapid clots lysis ? reduce pulm.
• hypertension
• 2. Reduce recurrent rate ? reduce
• mortality rate

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Thrombolytic Therapy (2)

• Risk stratification and individualization of
  therapy are important

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Thrombolytic Therapy (3)

• Bleeding risk 13
• Bleeding complication
• major bleeding ( 510 )
• ICH ( 12 )

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Inferior Vena Cava Interruption

• Placement of IVC filter increasing? long term
  outcome (?)
• Indications
• 1. Contraindication to anticoagulant
• 2. Failure of anticoagulation

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Transvenous Catheter Embolectomy

• In whom thrombolysis fails or is contraindicated
• Very ill and require a rapid approach

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Surgical Embolectomy

• Indications
• 1.massive PE with shock and too ill for
• thrombolytic therapy
• 2. Contraindication to or failure of
• thrombolytic therapy
• Mortality still high 2040
• Worse in those pre-op cardiac arrest

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Singapore Med J 2002 Jan43(1)025-7Massive
pulmonary embolism with haemodynamic collapse

• ?Massive pulmonary embolism with shock remains a
  highly fatal disease.
• ?12 cases of massive embolism over the last 7
  years that required emergent surgery. 5 patients
  suffered haemodynamic collapse and all died
  despite heroic attempts at salvage.
• ?A better outcome can only be achieved by a rapid
  confirmatory diagnosis and appropriate
  thrombolysis and early referral to a
  cardiothoracic surgeon.

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Circ J 2002 May66(5)479-83Treatment of acute
massive/submassive pulmonary embolism

• ?35 patients with massive and submassive
  pulmonary embolism (PE) were reviewed. In 75 of
  these cases, PE could be suspected on the basis
  of EKG alone?useful for diagnosing PE and
  assessing right ventricle after-load at the
  bedside.
• ?Spiral CT effective for obtaining a definitive
  diagnosis even in a relatively hemodynamically
  unstable patient.
• Thrombolysis therapy was given to 30 cases and
  was apparently effective in 17 cases (17/30,
  56.7).
• ?Percutaneous cardiopulmonary support (PCPS) was
  needed for 7 severe cases. Seven patients,
  including 5 of the PCPS recipients, underwent
  surgical embolectomy.
• ?Overall mortality was 28.6 (10/35), and
  surgical mortality was 28.6 (2/7).

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Ann Intern Med 2002 May 7136(9)691-700  
Echocardiography in the management of pulmonary
embolism.

• ?Echocardiography useful for identifying
• 1.Moderate or severe right ventricular
  hypokinesis,
• 2.persistent pulmonary hypertension,
• 3.patent foramen ovale, and free-floating
  right-heart thrombus
• ?are echocardiographic markers ? identify risk
  for death or recurrent thromboembolism.
• ?Such patients warrant consideration for
  thrombolysis or embolectomy.
• ?Serial imaging of right ventricular function
  ? help to monitor the effect of treatment and
  judge whether the selected management is
  successful.

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Australas Radiol 2002 Mar46(1)47-51Comparison
of lung scintigraphy and CT angiography in the
diagnosis of pulmonary embolism

• ? pulmonary angiography is not used in the
  diagnosis of pulmonary embolism in this study
  because of its perceived risks.
• compared the results on lung scintigraphy and
  computed tomography angiography (CTA) in 116
  consecutive patients with suspected pulmonary
  embolism.
• 1. 14 patients with normal lung scans 13 (93)
  were also normal with CTA. 2. 73 patients with
  low probability lung scans only 5 (7)
  demonstrated PE with CTA.
• 3. 17 patients with intermediate probability
  lung scans, 10 (58.8) showed embolism with CTA.
• 4. 12 patients with high probability lung
  scans 11 (92) demonstrated PE on CTA.
• Conclusion
• 1. practicable lung scans should be performed in
  all patients due to its relatively low radiation
  burden
• 2. CTA be performed in patients with intermediate
  probability scans due to the high incidence of
  pulmonary embolism.
• BUT in patients with low probability scans
  CTA should be performed in those with a high
  clinical suspicion of thromboembolism.

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Minerva Anestesiol 2002 Apr68(4)186-91Thromboly
tic therapy during cardiopulmonary resuscitation.

• ?Recently, efforts have been undertaken to
  investigate the effects of thrombolysis during
  (CRP) in patients suffering from massive PE or
  AMI
• one of these two diseases ?deteriorate?contribute
  up to 70 of cardiac arrest.
• Nevertheless, thrombolysis has not been conducted
  during CPR because of the fear of severe bleeding
  complications.
• ? However, an increasing clinical studies suggest
  that thrombolytic therapy during CPR can
  contribute to haemodynamic stabilisation and
  survival in patients with massive PE and AMI,
  when conventional CPR procedures have been
  performed unsuccessfully.
• ?Experimental data indicate that thrombolysis
  during CPR can improve microcirculatory
  reperfusion, which may be most important in the
  brain.
• ?In accordance with these data, marked
  activation of blood coagulation without adequate
  activation of endogenous fibrinolysis has been
  demonstrated early after cardiac arrest.
• ?thrombolysis during CPR is presently a
  treatment strategy ? can be performed on an
  individual basis in patients with PE or AMI. It
  may become a routine measure if positive results
  of randomised, controlled clinical trials will be
  available in the future.