imaging: pulmonary embolism
TRANSCRIPT
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Image of the weekJagdish K
Prof. Dr. A Gowrishankar’s unitm3
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65 yr old male, who is a known smoker for the past 40yrs, presented with acute worsening of pre existing long standing breathlessness, 10 days prior to presentation
No h/o fever, cough or expectoration
h/O fracture neck of femur after trivial fall in bathroom 3years back and he was not ambulant since then.
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O/E
◦ Pulse 110/min
◦ BP 130/80 mm of hg
◦ Conscious, oriented, afebrile
◦ Conjunctiva suffused
◦ CVS – S1 normal, P2 loud
◦ RS :B/L Wheeze+, Right base BS↓
◦ Other systems normal
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Chest X ray
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ECG
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exudative
60 lymphocytes/cumm
6 mesothelial cells/cumm
Ada – 16 iu/l
Pleural fluid analysis
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700ng/ml
D dimer
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CT Chest
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“ Few health care providers realise the case fatality rates for pulmonary embolism is 15%, exceeds that of acute MI”
Pulmonary embolism
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Risk factors
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Inherited
Acquired
Thrombophilias
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Endotelial injury
Stasis
Hypercoagulablility
Virchow’s Triad
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Most common symptoms & signs
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Well’s clinical decision rule
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Mild Moderate Severe Paradoxical Pulmonary infarction syndrome Nonthrombotic pulmonary embolism
Diverse clinical scenarios
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Pulmonary infarction syndrome
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Oxygen saturation
Chest x ray
D dimer
Investigations
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ECG changes
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Echocardiographic changes
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Multidetector CT – The one stop shop
CT Angiography
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CT PULMONARY ANGIOGRAM
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Lung scanning
Pulmonary angiography
Venous ultrasound
MRI
continued
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Clinical predictors of increased mortality
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Biomarkers & imaging predictors of increased mortality
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Approach to the patient
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Lack of written diagnostic algorithm
Failure to use clinical probability scoring
Ruling out pulmonary embolism based on normal venous ultrasound of legs
Not evaluating after finding an abnormally elevated D- dimer test
Delay in seeking medical attention
5 common errors
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“Can also occur concomitantly with other illnesses , thereby confounding the diagnostic work up”
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“ The greatest challenges are to remember to consider the possible diagnosis of pulmonary embolism and realise that it can masquerade as many other illnesses”
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THANK YOU