0071643192.pdf

■ V/Q scan

■ Matches inhaled radionuclide distribution (ventilation) to pulmonary

vasculature radionuclide (perfusion).

■ Normalperfusion=no PE.

■ High probability =definite PE.

■ Low probability with low clinical suspicion =no PE.

■ All others need further imaging.

■ Indications include renal failure, contrast allergy.

■ Less useful if underlying lung disease or abnormal CXR

■ Insensitive

■ Pulmonary arteriography: Classic gold standard, but mostly supplanted

by chest CT

■ Duplex ultrasound

■ Presumptive PE if +for DVT in correct clinical setting (negative test

nothelpful in excluding PE)

TREATMENT

■ Immediate anticoagulation with unfractionated heparin infusion or

LMW heparin

■ If heparin is contraindicated use thrombin inhibitor, such as lepirudin

or danoparoid.

■ Thrombolysisshould be used if there is clinical evidence of massive PE

(hypotension, cardiac arrest, evidence of R heart strain).

■ tPA is preferred agent (100 mg over 2 hours).

■ Contraindications similar to thrombolytics in MI (see Table 2.7).

■ No evidence that mortality is lowered, but will improve R heart function.

■ Embolectomy

■ Procedure of last resort in critically ill patient when thrombolysis is

contraindicated

■ IVC Filter

■ To prevent recurrent PE in patient with contraindications to anticoagu-

lation or with recurrent PE on anticoagulation

COMPLICATIONS

■ Cardiac arrest and death

■ Development of pulmonary hypertension

Venous Insufficiency

Chronic elevation of venous pressure can compromise the integrity of valves

in the deep and perforating veins in the leg. This results in edema, varicose

veins, and chronic changes in the skin and soft tissues.

CAUSES

■ DVT: Most common

■ Trauma

■ Others: Varicose veins, pelvic vein obstruction, AV fistula

EXAM

■ Edema is the earliest finding.

■ Later signs: Stasis dermatitis, varicosities, ulceration

CARDIOVASCULAR EMERGENCIES

Indications for thrombolysis in

PE =clinical evidence of

massive PE.