Clinical Manifestations Of Pulmonary Embolism Research Articles

Fat Emboli with Thrombocytopenia in A Patient Undergoing Operation for A 1/3 Medial Humerus Oblique Fracture

Fat embolism is a clinical syndrome characterized by the systemic spread of fat emboli which often occurs due to fractures in long bones. We report a 29 year old man with a diagnosis of a fracture of the medial third of the right humerus accompanied by thrombocytopenia which could be one of the clinical manifestations of pulmonary embolism. A 29 year old man came to the emergency room at RAA Soewondo Pati Regional Hospital with complaints of pain in his right hand 2 hours before entering the hospital. The patient felt pain after falling and slipping at home. Physical examination revealed tachycardia and tachypnea. Humeral x-ray revealed discontinuity in the medial 1/3 of the right humerus. The patient then underwent treatment for the fracture and the day after a routine blood test was carried out. Routine blood tests revealed thrombocytopenia.Fat embolism is a dangerous complication of long bone fractures. Often this fat embolism is not recognized until the patient shows symptoms in several systems, especially the respiratory system such as respiratory distress and neurological system disorders ranging from motor disorders to seizures. Apart from that, fat embolism can also disrupt the coagulation system so that thrombocytopenia can occur. In this patient there was tachypnea and thrombocytopenia which could be early symptoms of fat embolism. Fat embolism is a complication of long bone fractures that is rare but dangerous if not properly recognized. Immediate management of fractures and collaboration with anesthesiologists and internists are important to prevent fat embolism.

Application of CT pulmonary angiography and echocardiography in acute pulmonary embolism: A cross-sectional study.

Pulmonary Embolism (PE) is an acute and potentially fatal condition defined as the blockage of pulmonary arteries by an embolism that can be from various origins. The present study aimed to investigate the findings of computed tomography pulmonary angiography (CTPA) and echocardiography in patients with acute PE. The present cross-sectional study included some patients with clinical manifestations of PE who underwent CTPA and echocardiography. The radiologic findings, PE severity, and outcome of the patients were recorded. Moreover, echocardiography was performed by an expert cardiologist using a high-resolution device, while CTPA was performed by an expert radiologist using a 16-slice device and a two-step selective test bolus method. According to our findings, a total number of 147 patients were diagnosed with PE, including 44 (29.93%), 44 (29.93%), and 59 (40.14%) cases of mild, moderate, and severe PE, respectively. Moreover, 25 patients (17%) finally expired due to PE. Regarding the CTPA findings, 31 patients (21.1%) had septum flattening, while 35 (23.8%) had a septum deviation toward the left ventricle. Also, there were significant correlations between mortality and some CTPA findings, including severe PE (p < 0.001), the presence of septal deviation (p = 0.007), and higher diameters of the main pulmonary artery (p < 0.001) and right ventricle (p = 0.008). CTPA is a valid and accessible modality for diagnosing and evaluating PE in suspected patients. Moreover, several findings in CTPA could predict adverse outcomes, such as death, in patients with PE.

Pulmonary embolism masked by symptoms of mental disorders.

The objective of this article is to draw attention to an unusual clinical manifestation of pulmonary embolism (PE) as symptoms suggesting an underlying mental disorder. This seems all the more important since PE is one of the most common causes of potentially preventable hospital deaths and delayed diagnosis of PE in patients consulted at emergency departments has been shown to be most common in elderly patients and the ones presenting with significantly altered mental status. PE is a life-threatening condition that requires prompt diagnosis and appropriate management. There is no symptom that can be found characteristic for PE. Clinical picture of this condition is varied and may resemble many other disorders. The article emphasises that PE may also manifest with psychopathological symptoms that mimic psychiatric emergencies. Three most common groups of psychopathological symptoms that can mask a developing PE, such as panic attacks, symptoms of psychosis, and catatonia, are discussed here based on the literature review. Particular care must be exercised while evaluating such a patient because initial misdiagnosis results in the patient being referred to a mental health care unit instead of a unit treating somatic disorders. There are no diagnostic or treatment facilities in large psychiatric hospitals to assist such a patient. This, in turn, leads to a significant delay in management and, consequently, to major complications or death.

Differential Approach to Surgical and Endovascular Treatments of Pulmonary Thromboembolism in Patients with Neurological and Neurosurgical Problems

INTRODUCTION: Pulmonary embolism (PE) is one of the most threatening complications in patients with neurological and neurosurgical problems. The high epidemiological threshold values and mortality in the considered group of patients attracted the interest of researchers in the methods of early diagnosis and selection of methods of reperfusion of the pulmonary arterial bed.&#x0D; AIM: To analyze clinical and hemodynamic results of the surgical and endovascular treatment of PE of the high and intermediatehigh risks in the group of patients with neurological and neurosurgical problems.&#x0D; MATERIALS AND METHODS: This study involved 24 patients with PE of high and intermediate high-risks. The first group involved seven patients with neurosurgical problems who underwent thromboembolectomy from the main and lobular branches of the pulmonary artery in conditions of parallel perfusion of the artificial circulation. The duration of perfusion was 26.0 7.4 min. The second group consisted of 17 patients with acute hemorrhagic stroke, in whom endovascular mechanical fragmentation of thromboemboli was performed using a modified Pig-Tail type catheter introduced by puncture through the subclavian or jugular vein. The first clinical manifestations of PE appeared 4.78 2.02 days after the neurosurgical intervention and 8.45 2.6 days after the onset of stroke. The initial systolic pressure in the pulmonary artery was 67.24 5.15 mm Hg in the first group and 70.53 4.53 mm Hg in the second group. Both groups had American Society of Anesthesiologist physical status IV and V classes of surgical risk and Pulmonary Embolism Severity Index class V (130174 points).&#x0D; RESULTS: The hospital survival rates were 100% and 82.36% in the first and second groups, respectively (three lethal cases due to progressing right-ventricular failure in the first 18 h after the procedure). On discharge, signs of reverse remodeling of the right heart chambers and reduction of the mean and systolic pressure in the pulmonary artery to 21 2.16 and 31 4.12 mm Hg, respectively, were noted in the first group and to 46 5.23 and 57 3.16 mm Hg, respectively, in the second group.&#x0D; CONCLUSION: Surgical treatment of PE is effective and safe with predictable results. Endovascular catheter induced destruction of the thromboembolus substrate is an alternative to the surgical treatment of patients with a high-risk of open surgery and absolute contraindications for thrombolytic therapy.

Possibilities of Surgical Treatment of Pulmonary Embolism in Patients After Spinal Surgery

Aim of study. Comprehensive assessment of clinical and hemodynamic results of surgical treatment of high- and intermediate-high risk of pulmonary embolism in a group of patients who underwent spinal surgery.Materials and methods. The analysis of the results of open surgical treatment of pulmonary embolism in high- and intermediate-high-risk patients after neurosurgical operations on the spine in the period from 2013 through 2019. The study group included 5 patients. The average age of patients was 59.74±3.42 years. The Wells index was 9.2±2.4. The Pesi index of the studied patients was in the range of 100–126, which allowed them to be classified as a high-risk group of 30-day mortality (class IV). Clinical manifestations of pulmonary embolism developed on average by 5.8±1.08 days after the initial neurosurgical intervention. The calculated pressure in the pulmonary artery was 56.6±8.22 mm Hg. In all cases, surgical intervention was performed for emergency indications, in conditions of artificial blood circulation, without aortic compression during the main stage of the operation.Results. The 30-day survival rate of patients was 100%. Among non-lethal postoperative complications, acute cardiovascular failure and hepatic-renal failure prevailed, which were levelled by the time the patients were transferred to a cardiac hospital. In 1 patient, the early postoperative period was complicated by the development of exudative pericarditis with cardiac tamponade, which required a finger revision of the anterior mediastinum, its drainage for 2 days. In all cases, there was an improvement in the condition of patients, in the form of increased tolerance to physical activity. The estimated pressure in the pulmonary artery at the time of discharge was 24.69±8.03 mm Hg.Conclusions. Surgical treatment of acute pulmonary embolism of high- and intermediate-high risk of early death in a group of patients with a neurosurgical profile is a highly effective and reliable method with great prospects for application.

Clinical and angiopulmonographic association in pulmonary embolism

To detect the effect of the feature of the pulmonary vascular obstruction on the clinical manifestations of pulmonary embolism (PE). The 127 patients with PE were included in this study. PE verified with multidetector computed tomography with pulmonary angiography. Among them were 57 patients with high-risk PE, and 39 patients with intermediate-risk PE and 31 patients with low-risk PE. The pulmonary artery obstruction index and the obstruction level were determined. The mean values of the pulmonary artery obstruction index in high and intermediate risk patients were 42.5%, and in low risk patients 12.5% (p0.001). The trunk or main branches obstruction was in 80.7% of high-risk PE patients, the main or lobar branches obstruction in 92.3% of intermediate-risk patients and lobar or segmental branches obstruction in 93.5% of low-risk patients. Pulmonary infarction was detected in 89.2% of patients with the segmental branches obstruction and with another level of obstruction in 28.0% of patients only (p0.001). The hemodynamic disorder in pulmonary embolism associate with the pulmonary artery obstruction index of more than 30%. The development of obstructive shock is associated with the pulmonary artery trunk obstruction, and the development of pulmonary infarction associated with the segmental branches obstruction.

Nėštumas ir plaučių embolija

Plaučių embolija (PE) išsivysčiusiose šalyse yra viena dažniausių tiesioginių mirties priežasčių nėštumo metu ir ankstyvuoju pogimdyminiu laikotarpiu. Veninė stazė, kraujagyslių endotelio pažeidimas ir hiperkoaguliacija (Virchow triada) sąlygoja padidėjusią veninės trombų embolijos (VTE) riziką nėštumo laikotarpiu.Dažniausiai nėščiosioms nustatomi papildomi VTE rizikos veiksniai: nutukimas, nejudra, venų varikozė ir uždegiminės žarnyno ligos. Klinikinė PE diagnostika nėštumo laikotarpiu sudėtingesnė dėl moters organizmo fiziologinių pokyčių, kurių išraiška labai panaši į PE sukeliamus simptomus. Klinikinę PE tikimybę galima įvertinti naudojantWells klausimyną, remiantis jo rezultatais, sprendžiama dėl tolesnio tyrimo taktikos. Literatūroje atsiranda duomenų, kad galima saugiai atmesti PE diagnozę naudojantis YEARS algoritmu, taip išvengiant nereikalingo nėščiosios radiologinio tyrimo. Nėščiųjų PE gydymą lemia pusiausvyra tarp veiksmingo moters gydymo, vaisiaus saugumo ir padidėjusiosmoters kraujavimo rizikos.Nefrakcionuotas heparinas irmažosmolekulinėsmasės heparinai yra saugūs ir veiksmingi medikamentai PE gydymui nėštumo laikotarpiu. Siekiant išvengti nėščiųjų ir gimdyvių ligotumo ir mirštamumo, įvykus PE, būtinas individualusVTE rizikos veiksnių įvertinimas, tinkamas ir savalaikis gydymas bei profilaktika.

Differential clinical manifestations and clinical outcome of cancer-related pulmonary embolism.

Background/AimsAlthough acute pulmonary embolism (PE) adversely impacts survival and should be treated regardless of cancer, the treatment rate of cancer-related PE is relatively low. We aimed to compare clinical characteristics and long term prognosis of PE in patients with or without cancer.MethodsFrom March 2010 to December 2013, patients with newly diagnosed PE were analyzed. Baseline demographics, comorbidities, cancer status and clinical manifestations of PE were recorded. We defined primary composite outcome as recurrent venous thromboembolism (VTE) and death from PE.ResultsAmong a total of 976 patients with PE, the 703 (72.0%) had cancer-related PE. Cancer-related PE group was more frequently asymptomatic (54.5% vs. 13.2%, p < 0.001), less extensive (involvement of bilateral pulmonary arteries: 42.8% vs. 51.3%, p = 0.017; lung infarction: 5.3% vs. 10.3%, p = 0.005) and less likely to accompany right ventricular dysfunction (10.3% vs. 27.2%, p < 0.001) compared with the non-cancer PE group. Anticoagulation was less frequently underwent in patients with cancer-related PE than those without cancer (62.0% vs. 81.7%, p < 0.001). A composite of recurrent VTE and death from PE was significantly higher in the cancer-related PE group (14.4% vs. 6.6%, p = 0.001).ConclusionsAlthough PE in cancer patients were seem to be less aggressive initially, compared to those without cancer, they had significantly poor prognosis. Given a high rate of recurrent VTE and relatively similar risk of anticoagulation associated bleeding events in cancer patients, more active treatment of PE is warranted in cancer patients.

Combined shrapnel injury of the inferior vena cava which caused bulletpulmonary artery embolism (case report and review of the literature)

Bullet embolism is a rare and unpredictable complication of gunshot and mine‑explosive injuries. With only few cases described in the literature, bullet embolism may become a diagnostic challenge for emergency and military surgeons. Thus, bullet embolization is a rare phenomenon, the complications can be devastating.A clinical case of bullet embolism is described. 34‑years old man got combined abdominal‑skeletal mine‑explosive injuries with damage to hollow organs (duodenum and transverse colon), inferior vena cava and both low extremities. Internal bleeding was stopped by the inferior vena cava edge wound suturing. Wounds of duodenum and large intestine were sutured; gunshot fractures of both tibial bones were stabilized with external fixation devices. Computer tomography of the entire body showed the presence of embolus in the right middle lobe artery. Clinical manifestations of pulmonary embolism were not observed. The patients had several complications after surgery such as: multiple focal necrosis and perforations of transverse colon caused a fecal peritonitis; duodenum suture failure caused forming of a duodenal fistula; postoperative wound infection. These complications necessitated performing of multiple reoperations. Attempts of endovascular bullet extraction didn’t undertake because of severe concomitant injuries, its complications and asymptomatic clinical course of pulmonary artery projectile embolism. Open surgery removing of embolus was successfully performed in 80 days after injury. The patient was discharged from hospital in good condition in 168 days after gunshot wound. Patients with an explosive‑mine wound and gunshot wound with no exit should to be examined with whole‑body computer tomography for determining possible projectile migration with bloodstream. Patients with asymptomatic pulmonary artery embolism should to be managed non‑operatively in the early posttraumatic period. In case of symptomatic pulmonary artery bullet embolism is reasonable to consider of a possibility of an open thoracic surgery.

Dva lica plućne embolije

Objective. The aim of this paper is to present two completely different clinical manifestations of pulmonary embolism which the author encountered in the field. In both cases CT angiography confirmed massive embolism. Methodology. The data from medical documentation were used to present cases of two patients with pulmonary embolism. Case report. The first one presents a case of a 62-year-old man who called emergency service because of a sudden intense pressure-like chest pain, accompanied by sweating and tingling in both hands. Physical exam showed tachypnea, SaO2 of 80%, with auscultatory finding of weakened breath sound on left side basal, BP= 110/60 mmHg on both sides. ECG registered sinus rhythm, HR = 90 / min, new incomplete right bundle branch block and flattened T wave in precordial leads. Patient's history revealed an oncologic diagnosis, plaster immobilization on right lower leg and previous pulmonary embolism 9 years ago. The patient was transported to the emergency medical institution, with suspected diagnosis of pulmonary embolism, which was eventually confirmed by CT pulmonary angiography. The other is the case of a 48-year-old man presenting with short-term loss of consciousness followed by spontaneous recovery, which was the reason for contacting the emergency service. Healthy, former active athlete, without any risk factors for cardiovascular disease, also without predisposing factors for the development of deep vein thrombosis. Upon our arrival, he complained only of languor. Physical exam showed eupnea, with normal breath sounds, SaO2 98%, BP= 120/80 mmHg on both sides. The ECG registered sinus rhythm, HR= 110 / min, QS in V1-V3, ST elevation 1mm in V2-V3. The patient was transported to the cardiology department. Because of the hs troponin T= 194, he was admitted to the cardiology ICU with a working diagnosis of acute myocardial infarction. Subsequent CT angiography registered a massive pulmonary embolism. Discussion and conclusion. In order to make the correct diagnosis of pulmonary embolism, it is necessary to keep high level of suspicion. The fact that clinical signs and symptoms are not specific is the reason why PE often isn't diagnosed in time or remains unrecognized in some cases. In field conditions, with limited diagnostic possibilities, establishing the diagnosis of PE is particularly challenging. In all cases of unexplained syncope and tachycardia, the possibility of PE should be considered. We need to think about pulmonary embolism even when risk factors are absent.

Clinical relevance of syncope in patients with pulmonary embolism

BackgroundSyncope is an unusual clinical manifestation of pulmonary embolism (PE), and the clinical significance of syncope in PE patients remains controversial. We investigated the incidence of syncope, examined the clinical factors associated with syncope, and assessed the association between syncope and the short-term outcomes of PE. MethodsWe retrospectively classified patients presenting with PE into 2 groups: patients with syncope and those without syncope. We compared the clinical and computed tomography parameters between the groups. ResultsAmong 1084 patients diagnosed with PE, 45 (4.2%) presented with syncope. Four patients which presented with cardiac arrest were excluded from the study. The syncope group showed significantly higher blood biomarker levels and higher rates of central PE and right ventricular dilation than the control group. Unprovoked PE (odds ratio [OR] 8.046, 95% confidence interval [CI] 3.073–21.069, p < 0.001), female sex (OR 3.419, 95% CI 1.348–8.675, p = 0.010), central PE (OR 2.854, 95% CI 1.298–6.278, p = 0.009), and troponin I level (OR 2.812, 95% CI 1.765–4.480, p < 0.001) were observed to be independent factors associated with syncope in PE patients. However, multivariate analysis showed that the presence of syncope was not a significant predictor of adverse outcomes and recurrent venous thromboembolism in PE patients. ConclusionsAlthough syncope is associated with a more severe form of PE, it does not influence the short-term prognosis of PE. Central PE, blood troponin I level, unprovoked PE, and female sex were observed to be clinical factors related with syncope in patients with PE.

Contributors

Syncope is an unusual clinical manifestation of pulmonary embolism (PE), and the clinical significance of syncope in PE patients remains controversial. We investigated the incidence of syncope, examined the clinical factors associated with syncope, and assessed the association between syncope and the short-term outcomes of PE.We retrospectively classified patients presenting with PE into 2 groups: patients with syncope and those without syncope. We compared the clinical and computed tomography parameters between the groups.Among 1084 patients diagnosed with PE, 45 (4.2%) presented with syncope. Four patients which presented with cardiac arrest were excluded from the study. The syncope group showed significantly higher blood biomarker levels and higher rates of central PE and right ventricular dilation than the control group. Unprovoked PE (odds ratio [OR] 8.046, 95% confidence interval [CI] 3.073–21.069, p < 0.001), female sex (OR 3.419, 95% CI 1.348–8.675, p = 0.010), central PE (OR 2.854, 95% CI 1.298–6.278, p = 0.009), and troponin I level (OR 2.812, 95% CI 1.765–4.480, p < 0.001) were observed to be independent factors associated with syncope in PE patients. However, multivariate analysis showed that the presence of syncope was not a significant predictor of adverse outcomes and recurrent venous thromboembolism in PE patients.Although syncope is associated with a more severe form of PE, it does not influence the short-term prognosis of PE. Central PE, blood troponin I level, unprovoked PE, and female sex were observed to be clinical factors related with syncope in patients with PE.

Clinical significance of peculiarities of the lesions of the vascular bed associated&#x0D; with pulmonary thromboembolism

Aim. To study effect of the level of vascular obstruction on the clinical manifestations of pulmonary embolism (PE). Material and methods. 63 patients with PE were included in this study. PE was verified by multidetector computed tomography (MSCT) with pulmonary angiography. 43 patients with high-risk PE survived the first week of the disease. In the remaining 20 patients with community-acquired pneumonia PE was diagnosed using MSCT pulmonary angiography in the first week of illness. Results. Obstruction of the trunk of the pulmonary artery or its lobar branches was detected in 34 (79.1%) patients with a high risk of PE and in only 2 (10%) ones with low-risk PE (p &lt;0,001). The development of pneumonia complicated the course of the disease in 14 (32.6%) patients with a high risk of pulmonary embolism. The clots in the segmental branches of the pulmonary artery were identified in 9 (64.3%) patients with pneumonia. In high-risk patients with PE without pneumonia the lesion of segmental branches was detected only in 1 (3.4%) case (p &lt;0,001). In patients with pneumonia at low risk of PE, the obstruction segmental branches was detected in 17 (85%) cases. Conclusion. The development of obstructive shock in PE is associated with a trunk embolism and/or the main pulmonary artery branches embolism. Infarction pneumonia is associated with the lesions of segmental branches of the pulmonary artery.

Acute Surgical Abdomen: An Unusual Presentation of Pulmonary Embolus.

Background. Pulmonary embolism is a common and potentially lethal condition. Most patients who die from massive pulmonary embolism do so within the first few hours of the event. The clinical manifestations of pulmonary embolism are nonspecific, which makes the diagnosis difficult. Case Report. We present a case of massive pulmonary embolism presenting as an acute surgical abdomen that underwent exploratory laparotomy and made a complete recovery. Why should an emergency physician be aware of this? Emergency department physicians should be aware that massive pulmonary embolism could present as an acute surgical abdomen in young healthy individuals.

EComment. Surgical complications of permanent cardiac pacemaker insertion

We read with interest the manuscript by Wu and Chen and we would like to comment on the surgical complications of intracardiac pacemaker implantation [1]. The use of permanent pacemakers (PPM) and implantable cardioverter-defibrillators (ICD) is increasing due to the expansion of indications and aging of the population. As a consequence, cardiologists and cardiothoracic surgeons have to deal with a broad spectrum of complications, which are sometimes under-estimated and life-threatening. The surgical complications of PPM and ICD may occur during the immediate or early post-operative period and can be related to venous access process (pneumothorax, hemothorax, air embolism, haematoma, arterial puncture, wound healing problems, infection, pain), to the pacemaker lead (cardiac perforation, tamponade, malposition or dislodgement of the lead), or to the generator device. In addition, other complicationed that may occur during the late post-operative period are related to infections, thrombosis, endocarditis, pulmonary embolism, superior vena cava (SVC) syndrome (due to thrombus formation and/or fibrosis of the pacing wires within the SVC) and pericarditis [2-5]. Ostovan and Aslani have reported on the successful treatment of massive pulmonary air embolism during a PPM implantation with air suctioning by the guide catheter inserted into main pulmonary artery via the left femoral vein. Treatment for air embolisms includes oxygen treatment, haemodynamic support and prevention of further air entry in the systemic circulation. The left lateral decubitus position can prevent the air obstruction of the pulmonary outflow tract (air can be moved toward the right ventricular apex) [2]. Aggarwal et al. found no difference in the incidence of intraoperative and early postoperative complications (up to two months after implantation) between single and dual chamber pacing systems [3]. Sohail et al., in their retrospective review of 189 patients with pacemaker related infections, found out that the most common clinical presentations were generator pocket infection (69%) and device-related endocarditis (23%). The leading pathogens were Coagulase-negative Staphylococci and Staphylococcus aureus, in 42% and 29% of cases, respectively. There was a broad spectrum of related complications such us septic arthritis, sternal or vetebral or femoral osteomyelitis, and abscesses in lung, spleen, liver, brain and perinephric area. Twenty-two (11.6%) patients had thrombosis of the subclavian vein or superior vena cava and 6 of them developed clinical manifestations of pulmonary embolism. Ninety-eight percent of patients underwent complete device removal combined with antibiotic treatment and 96% of patients were treated successfully [4]. Nineteen patients had lead extraction via a median sternotomy and the rest underwent percutaneous lead extraction. Interventional complications were more common in patients with a history of multiple device-related procedures and were related to tricuspid valve failure, laceration of subclavian vein, hemothorax, haematoma, fracture of lead tip, ventriculotomy and bleeding [4]. Right atrial thrombosis and pulmonary embolism are infrequent complications (0.6%-3.5%) and its therapeutic modalities include anticoagulation, thrombolysis and or surgery [5]. In conclusion, the knowledge of all potential complications of the PPM/ICD and its multidisciplinary approach is very important for its prevention and definitive treatment. Conflict of interest: none declared

Gemstone computed tomography in the evaluation of material distribution in pulmonary parenchyma for pulmonary embolism

To present our initial experiences with pulmonary high-definition multidetector computed tomography (HDCT) in patients with acute venous thromboembolism (AVTE) to evaluate their corresponding clinical manifestations. Since December 2009 to March 2010, 23 AVTE patients underwent HDCT at our hospital. Pulmonary embolism (PE) was diagnosed based on the 3D-reconstructed images of computed tomography pulmonary angiography (CTPA). The post processed data were collected by spectral imaging system software to detect the iodine distribution maps. Perfusion defects, calculated as the values of iodine content, were compared with those of normal lung parenchymal perfusion in the absence of PE. Among them, 14 AVTE patients were definitely diagnosed with PE. Prior to anticoagulant therapy, their values of iodine content in defective perfusion area were significantly lower than those in normal perfusion area. After a 3-month anticoagulant therapy, the values of iodine content for the defective perfusion area increased significantly (P < 0.05). There was no significant correlation between the values of iodine content for segmental/subsegmental filling defect area and clinical risk score of DVT (r = 2.68, P > 0.05). But there was a significant negative correlation between the values of iodine content for segmental/subsegmental filling defection area and clinical probability score of PE (r = 0.78, P < 0.05). HDCT is a promising modality of visualizing pulmonary microvasculature as a correlative manifestation of regional perfusion. PE results in hypoperfusion with decreased values of iodine content in affected lung parenchyma. Hemodynamic changes in affected areas correlate with the severity of clinical manifestations of PE.

Overutilization of CT Pulmonary Angiogram for Diagnosis of Pulmonary Embolism - Opportunities for Improvement

PURPOSE: Clinical manifestation of pulmonary embolism (PE) is non-specific and the physician's judgment is often inaccurate. Though CTPA (CT Pulmonary Angiography) is the gold standard, the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED II) study advocated conservative use of CTPA based on high pretest probability. However, despite the cost and complications, CTPA is often abused. The purpose of the study is to examine if CTPA was appropriately utilized based on Revised Geneva Score (RGS) and validated algorithm.

Incidence and Outcome of Pulmonary Embolism following Popliteal Venous Repair in Trauma Cases

Objectives and design Popliteal vein repair and ligation are the two main approaches to the treatment of the venous component of major, complex, knee injuries with vascular involvement. We have studied the incidence of pulmonary embolism following popliteal vein repair in trauma cases using computed tomography (CT) angiography and report the outcome. Material and methods From June 2006 to December 2009, 45 patients with popliteal vein injury were operated on in our vascular unit using lateral venorrhaphy, end-to-end anastomosis, a saphenous vein interposition graft and venous patch repair. All the patients were operated on using a medial approach to the knee. On the third postoperative day, all patients underwent a colour Doppler scan of the repaired popliteal vein to study patency, and pulmonary artery CT angiography using a 64-slice multidetector CT scan unit to establish the incidence of pulmonary embolism. Results The number of patients treated by each method were: lateral venorrhaphy 20 (44%), end-to-end anastomosis 13 (29%), saphenous vein interposition graft 9 (20%) and venous patch repair three (7%). Two patients (4%) died because of sudden cardio-respiratory arrest the day after surgery with massive bilateral pulmonary artery embolism at autopsy. Popliteal colour duplex ultrasound imaging showed seven (16%) cases of complete vein thrombosis and seven (16%) cases of partial vein thrombosis. CT angiography showed pulmonary embolism in 11 (26%) patients. From seven patients with complete thrombosis three patients, and from seven patients with incomplete thrombosis five patients showed pulmonary embolism on CT angiography. Other than two cases of early mortality, five (12%) patients developed clinical manifestations of pulmonary embolism and 11 (26%) patients had pulmonary embolism detected by CT angiography. Seven (16%) of our patients had mild-to-severe pulmonary embolism and 13 patients (29%) had proven pulmonary embolism. The total mortality rate was 7%. Conclusion A surprisingly high incidence of pulmonary embolism was observed after popliteal vein repair in civil trauma patients. Additional prophylactic methods such as using higher doses of heparin and using inferior vena cava (IVC) filters might be needed to prevent this potentially fatal complication.

Prognostic factors of poor outcome in patients with ischemic heart disease and pulmonary embolism

Summary. Patients with ischemic heart disease (IHD) have a high risk of the death during the first year after an episode of pulmonary embolism (PE). This study involved 71 patients with IHD and PE. Data of medical history, clinical manifestations and laboratory findings were analyzed. Factors predictive for poor outcome in patients with IHD and PE were age &gt; 65 yrs, concomitant chronic obstructive pulmonary disease, malignancies, seizures and severe hypertension as clinical manifestations of PE, the left ventricle ejection fraction &lt; 45 %, pulmonary artery systolic pressure &gt; 50 mmHg, diameter of the pulmonary artery &gt; 28 mm.

Pulmonary embolism in intensive care unit: Predictive factors, clinical manifestations and outcome

OBJECTIVE:To determine predictive factors, clinical and demographics characteristics of patients with pulmonary embolism (PE) in ICU, and to identify factors associated with poor outcome in the hospital and in the ICU.METHODS:During a four-year prospective study, a medical committee of six ICU physicians prospectively examined all available data for each patient in order to classify patients according to the level of clinical suspicion of pulmonary thromboembolism. During the study periods, all patients admitted to our ICU were classified into four groups. The first group includes all patients with confirmed PE; the second group includes some patients without clinical manifestations of PE; the third group includes patients with suspected and not confirmed PE and the fourth group includes all patients with only deep vein thromboses (DVTs) without suspicion of PE. The diagnosis of PE was confirmed either by a high-probability ventilation/perfusion (V/Q) scan or by a spiral computed tomography (CT) scan showing one or more filling defects in the pulmonary artery or in its branches. The diagnosis was also confirmed by echocardiography when a thrombus in the pulmonary artery was observed.RESULTS:During the study periods, 4408 patients were admitted in our ICU. The diagnosis of PE was confirmed in 87 patients (1.9%). The mean delay of development of PE was 7.8 ± 9.5 days. On the day of PE diagnosis, clinical examination showed that 50 patients (57.5%) were hypotensive, 63 (72.4%) have SIRS, 15 (17.2%) have clinical manifestations of DVT and 71 (81.6%) have respiratory distress requiring mechanical ventilation. In our study, intravenous unfractionated heparin was used in 81 cases (93.1%) and low molecular weight heparins were used in 4 cases (4.6%). The mean ICU stay was 20.2 ± 25.3 days and the mean hospital stay was 25.5 ± 25 days. The mortality rate in ICU was 47.1% and the in-hospital mortality rate was 52.9%. Multivariate analysis showed that factors associated with a poor prognosis in ICU are the use of norepinephrine and epinephrine. Furthermore, factors associated with in-hospital poor outcome in multivariate analysis were a number of organ failure associated with PE ≥ 3.Moreover, comparison between patients with and without pe showed that predictive factors of pe are: acute medical illness, the presence of meningeal hemorrhage, the presence of spine fracture, hypoxemia with PaO2/FiO2 ratio <300 and the absence of pharmacological prevention of venous thromboembolism.CONCLUSION:Despite the high frequency of DVT in critically ill patients, symptomatic PE remains not frequently observed, because systematic screening is not performed. Pulmonary embolism is associated with a high ICU and in-hospital mortality rate. Predictive factors of PE are acute medical illness, the presence of meningeal hemorrhage, the presence of spine fracture, hypoxemia with PaO2/FiO2 < 300 and the absence of pharmacological prevention of venous thromboembolism.