Diagnosis Of Pulmonary Thromboembolism Research Articles

The Diagnostic Value of End-tidal Carbon Dioxide (EtCO2) and Alveolar Dead Space (AVDS) in Patients with Suspected Pulmonary Thrombo-embolism (PTE)

Introduction: Capnography, is an easy, fast and practical method which its application in the diagnosis of Pulmonary Thromboendarterectomy (PTE) has recently been studied. This study aimed to assess the diagnostic value of end-tidal CO2 (ETCO2) and the alveolar dead space (AVDS) in the diagnosis of patients suspected to PTE who have been referred to the emergency department. Materials and Methods: This cross-sectional study was conducted during one year in the emergency department of Ghaem Hospital on patients with suspected PTE who scored less than 4 for the Wells’ criteria during the initial evaluation. After excluding other differential diagnoses, all patients underwent CT pulmonary angiography (CTPA) to confirm PTE. Following that, arterial blood gas sampling, ETCO2 and AVDS were requested for all the patients based on capnography. Data analysis was performed using descriptive statistical tests in SPSS software version 11.5. The sensitivity, specificity, and positive and negative predictive values of AVDS and ETCO2 were measured based on (CTPA) results. Results: The study was performed on 78 patients (mean age of 47.08± 15.6 years, 43 males/35 females) suspected to PTE. According to the results of CTPA, 37 patients did not develop PTE while 41 patients were with PTE. There was no significant difference between the two groups in terms of age and gender (P=0.999), while a statistically significant difference was found between the mean values of ETCO2 and AVDS between the two groups (P<0.001). The best cut-off points for PTE diagnosis were 0.17 (based on AVDS, with sensitivity and specificity of 78.0% and 56.8%, respectively), and 26.5 (based on ETCO2, with sensitivity and specificity of 67.6% and 75.6%, respectively). In addition, the negative predictive values for AVDS and ETCO2 were estimated as 70.0% and 71.43%, respectively. Conclusion: According to the results of this study, capnography could be effective to promptly rule out PTE in emergency situations. Given its negative predictive value to rule out PTE, ETCO2 is considered as the most valid criterion among capnography parameters.

Pulmonary artery intimal sarcoma mimicking pulmonary thromboembolism in a known case of urothelial carcinoma: a case report

Intimal sarcoma of the pulmonary artery is a rare tumor, which often mimics pulmonary thromboembolism both clinically and radiologically. Hence, the correct diagnosis is either delayed or it is misdiagnosed. It has a poor prognosis if not resected in time. Therefore, considering it in the differential diagnosis of pulmonary thromboembolism can help in early and accurate diagnosis, thereby improving patient outcome. We describe clinical, radiological, histopathological, and immunohistochemical findings of one such case in a 57-year-old gentleman, a known case of urothelial carcinoma who presented with dyspnea and was misdiagnosed as pulmonary thromboembolism.

Demographic characteristics of patients with pulmonary thromboembolism

Objective: Pulmonary thromboembolism (PTE) is a common disease with high mortality and difficult diagnosis. The incidence in our country cannot be calculated because there is no adequate and regular data. In our study, we aimed to investigate the demographic characteristics, risk factors, incidence, Wells and Geneva scores diagnostic and treatment methods of the patients in our emergency department with a diagnosis of PTE. Methods: Files of the 112 patients who were admitted to Erciyes University Medical Faculty Emergency Department between January 2010 - February 2012 were analyzed retrospectively. Data were analyzed with SPSS 17.0 statistical software. Results: The mean age of patients was 65.02 ± 16.23. Forty-one (36.6%) of the patients were male and 71 (63.4%) were female. The most common complaint of patients was shortness of breath (81.3%), respectively. Immobilization(35.7%) and history of previous surgery (19.6%) were among the risk factors of the patients. Average troponin levels of the patients was 0.13 ± 0.48 ng/L and average d-dimer levels was 12.698.12 ± 8.779.92 µg/L. Geneva scores of the patients were: 4 patients (3.6%) low score, 88 patients (78.6%) medium score and 20 patients (17.9%) high score. Wells Clinical Probability scores of the patients were; 1 patient (0.9%) low probability, 74 patients (66.1%) intermediate probability and 37 patients (33%) high probability. In the treatment of patients; heparin infusion (36.6%), enoxaparin sodium (59.8%) and tPA (3.6%) were used. Conclusion: In spite of improvements in diagnosis and treatment methods, pulmonary embolism diagnosis is stil a problem. The first step to diagnosis in patients with risk factors begin to suspect. J Clin Exp Invest 2015; 6 (1): 10-15 Key words: pulmonary embolism, diagnosis, treatment, demographic characteristics

A Retrospective Evaluation of Patients Admitted to Emergency Departments with Pulmonary Thromboembolism

2 , Bulent Sisman 3 Abstract Aim: To examine the clinical, radiological, and laboratory findings of pulmonary thromboembolism (PTE) patients who were admitted to our emergency depart - ment and to evaluate the effectiveness of clinical diagnosis scores. Materials and Methods: We retrospectively evaluated 33 PTE patients who were referred to our emergency department. Results: The mean age of the patients was 56.2±18.2 years. The female:male ratio was 1.5. The most common cause of complaints was dyspnoea (51.5%). Risk factors in the majority (39.3%) included immobilisation due to surgery. According to the Wells clinical scoring system, 29 patients (87.8%) had a high probability of PTE; however, 18 of the patients (55.5%) had high probability of PTE according to the modified Geneva score. The estimated rate ratio of high probability of PTE with the Wells score was statistically significant compared with the estimate rate ration with the modified Geneva score (p=0.017). The most common clinical findings included tachypnoea (69.6%) and tachycardia (27.3%). Fifteen (45.4%) patients had pathologic chest X-ray findings. Computed tomographic (CT) angiography most often showed PTE placement of the bilateral pulmonary main branches. While standard low-molecular-weight heparin and warfarin treatment was administered to 27 (81.8%) patients, tissue plasminogen activator (tPA) treatment was administered to 6 (18.2%) patients. Conclusion: The evaluation of clinical, laboratory and radiological findings together in PTE diagnosis is important. It is preferable to use the Wells score for the estimation of clinical probability in patients with suspected PTE. (JAEM 2015; 14: 8-11)

Comparison of multidetector computed tomography findings with clinical and laboratory data in pulmonary thromboembolism.

SummaryBackgroundPulmonary thromboembolism (PTE) is a common disease with a high mortality rate that is difficult to diagnose and treat. Because of the variety of clinical symptoms and signs, it is difficult to diagnose. Therefore, the diagnosis of PTE is mainly confirmed by imaging techniques. The aim of this study was to evaluate whether there is any corelation of the Wells rule, D-dimer and LDH values with computerized tomography pulmonary angiography (CTPA) findings in PTE diagnosis.Material/MethodsA consecutive series of 62 patients, which included 31 males and 31 females, with high/moderate/low risk of embolism according to Wells pulmonary embolism score, selected from the emergency service and/or outpatient clinic, enrolled in this prospective study. The patients with clinical or laboratory findings of elevated D-dimer level or elevated lactate dehydrogenase (LDH) level were suspected of embolism and underwent tomography.ResultsPTE was detected in 26 patients (42%). A significant difference was not detected between tomography finding positive and negative embolisms in the patient group in terms of age or gender distribution (P=0.221 and P=0.416, respectively).No significant difference was detected between tomography finding positive and negative embolisms in the patient group in terms of elevated LDH or/and D-dimer levels (P=0.263 and P=1.000, respectively).The distribution of low-risk-factor patients in the non-embolism group, and the distribution of high-risk-factor patients in the embolism-positive group was statistically significantly high (P<0.001). There was no statistically significant difference between the groups (P=0.053).Correlation test showed no correlation between LDH and D-dimer levels. (r=0.214, P=0.180).ConclusionsIn conclusion, when a patient presents with chest pain, our carrying out LDH and D-Dimer tests will not exclude PTE without CTPA. However, we suggest that LDH isoenzymes should be studied in further research.

Embolia pulmonar en el paciente oncológico: bases para el estudio EPIPHANY

Pulmonary thromboembolism (PE) is a common cause of morbidity and mortality in patients with cancer. Having cancer is an independent risk factor for death in the general series of patients with PE and is included as a variable in the prognostic scales of acute symptomatic PE. This fact limits the discriminatory power of these general scales for patients with cancer and has prompted the development of specific prognostic tools: POMPE-C and a scale derived from the RIETE registry. Whether the increased risk of death by PE in patients with cancer is due to complications related to the neoplasm or to a greater severity of the thromboembolic episode in this population has not been well studied. Moreover, the introduction of computed multidetector tomography in recent years has led to a growing diagnosis of incidental PE, which currently represents up to half of pulmonary embolisms in patients with cancer. The EPIPHANY study attempts to further the understanding of the characteristics of pulmonary embolisms in patients with cancer by including incidental and symptomatic events. Its primary objectives are a) to understand the clinical and epidemiological patterns of pulmonary embolism associated with cancer and b) to develop and validate a specific prognosis model for PE in this population. The registry includes variables of interest to oncology (cancer type and extent, oncospecific treatments, patient's functional condition, cancer progression), radiological variables (thrombotic burden, signs of ventricular overload and other findings), location of treatment (hospital or outpatient), acute complications and causes of death in patients with PE associated with cancer.

肺动脉栓塞影像及诊疗研究进展

肺动脉栓塞作为近年来发病率较高的一种心血管疾病，临床上具有较高病死率及误诊率，在国内外已经被列为重要的医疗保健问题之一，备受关注。近年来随着肺栓塞诊断意识和各种检查技术的提高，对肺栓塞的诊断和及时治疗例数已明显提高。特别是随着和各种计算机软件技术的不断发展和影像设备的不断更新，CT和MRI在PE临床诊疗的应用价值日趋明显。特别是64及以上高排螺旋(MSCTA) CTPA，它结合多平面重建等各种后处理技术能形成等于甚至超过许多经典血管造影图像，从而使其影像评估有了较大进展，本文通过查阅国内外文献阐述了肺栓塞的研究进展，包括发病机理及各种检查手段的优缺点以及病理临床表现，主要阐述CTPA作为无创条件下首选检查手段的最新进展和独有的特点及优势。对各项检查的优缺点和可行性以及合理性进行探讨，提高对肺血栓栓塞症的早期诊断水平，降低在临床中的误诊率和漏诊率，使患者得到及时诊治，同时简述各种治疗方法的临床应用价值，使患者能够选择适合的治疗方法，从而降低患者死亡率，提高其生活质量。 In recent years, pulmonary embolism as a higher incidence of cardiovascular disease, with high mortality and clinical misdiagnosis rate, at home and abroad has been listed as one of the major health problems of concern in recent years. With the diagnosis of pulmonary embolism and raise awareness of various inspection techniques, diagnosis and timely treatment of several cases of pulmonary embolism has been significantly improved. Especially with the various computer soft-ware technology and the continuous development of imaging equipment and constantly updated, CT and MRI in diagnosing PE clinical diagnosis has become more evident. Especially high slice spiral 64 and above (MSCTA) CTPA, which combines multi-planar reconstruction and other post- processing techniques to form equal or exceed many of the classic angiographic image, the image so that it has made significant progress in the assessment, this article by referring to domestic foreign literature describes the research progress of pulmonary embolism, including the advantages and disadvantages as well as the clinical and pathological manifestations and pathogenesis of various examination methods, mainly on CTPA as the preferred means of non-invasive examination of the latest developments and conditions of the unique features and advantages. Advantages and disadvantages and feasibility of the various checks and rationality to explore, improve the early diagnosis of pulmonary thromboembolism, reducing the clinical misdiagnosis and missed diagnosis rate, so that patients receive timely treatment, while a variety of treatment outlined the clinical value of the method, so that patients can choose the appropriate treatment to reduce mortality and improve their quality of life.

Qualitative evaluation of pulmonary CT angiography findings in pregnant and postpartum women with suspected pulmonary thromboembolism.

Background:Considering the importance of using more appropriate imaging technique for accurate diagnosis of pulmonary thromboembolism (PTE) with less side effects, we aimed to evaluate the quality of pulmonary 64-multidetector computed tomographic (MDCT) angiography in pregnant and postpartum women with suspected PTE in Isfahan.Materials and Methods:In this descriptive study, radiological findings of pregnant and postpartum women with suspected PTE who underwent pulmonary 64-MDCT angiography were evaluated. Prevalence of PTE in pregnant and postpartum women, mean of pulmonary arteries density for right and left pulmonary arteries, and their lobar and segmental branches, diagnostic quality of the pulmonary arteries density and their scoring, frequency of diagnostic and nondiagnostic images, mean of radiation dose and mean of bolus time, and the correlation between the quality of the vascular density with the peak density of the pulmonary artery were determined.Results:In this study, 44 pregnant and postpartum women with suspected PTE were selected. The overall prevalence of PTE was 9.1% (4/44). PTE was diagnosed in 1 (3.7%) pregnant and 3 (17.5%) postpartum women (P = 0.14). Mean density of pulmonary trunk was 278.81± 108.16 Hounsfield unit (HU) and 308.41 ± 59.30 HU in pregnant and postpartum women, respectively. Mean of bolus timing, kilovoltage peak (kVp), tube current, and dose length product (DLP) were 12.53 ± 2.36 s, 105.22± 45.71 milliamperage (MA), 382.9 ± 173.5 MA, and 317.98 ± 78.92 mGy/cm, respectively. The rate of nondiagnostic images was 4.5%.Conclusion:Our findings indicated that pulmonary 64-MDCT angiography is an appropriate imaging method for diagnosing PTE in pregnant and postpartum women with suspected PTE. It seems that, using fast CT systems (64-MDCT), in accordance with high flow rate, high contrast medium concentration and low kVp could explain the obtained appropriate quality of images more efficiently than computed tomographic pulmonary angiography (CTPA).

Pulmonary thromboembolism after caesarean section: A case report

The death of a female during pregnancy period, independent from the gestational age and localization or in a 42 day period after the end of pregnancy due to pregnancy related reasons or reasons aggravated by the pregnancy, but containing no relation with accidental or forced incidents, is defined as maternal death by the World Health Organization. Discussion of the requirements for an emboli diagnosis in an autopsy practice through literature data is aimed in our study. It has been reported that the case was 38 years old, G5 P4 and died with a respiratory distress occurred during the follow ups in 24 hours after the caesarean section. In autopsy, the body mass index was calculated as 32.8 kg/m2 (obese) and thrombus was detected in pulmonary arteries of both lungs. Thrombus was confirmed also through histopathological analysis. Evaluation of the medical history and data obtained from a detailed autopsy are of great importance for maternal deathswhich may occur after a caesarean section and involve a pulmonary thromboembolism diagnosis in order to determine the cause of death and prevent a loss of right in medical malpractice claims.

The Diagnosis of Acute Pulmonary Embolism

This paper reviews the most current literature on the diagnosis of pulmonary thromboembolism. The epidemiology and symptomology of this disorder, including common symptoms such as fever, chest pain, dyspnea, edema, and syncope, are reviewed. The utility of basic and easily available testing, such as electrocardiography and chest radiography, is evaluated. The literature on determining the pretest probability of venous thromboembolism with scoring systems, such as the Wells Score, the Geneva Scoring System, and the Pulmonary Embolism Rule Out Criteria, is appraised. As the evaluation of pulmonary embolism has evolved, multiple imaging techniques has been developed and studied. Ultrasonography, computed tomography with angiography, magnetic resonance angiography, ventilation perfusion lung scanning, and SPECT ventilation-perfusion lung imaging are discussed. In conclusion, the diagnosis of pulmonary embolism remains complicated. Clinical suspicion and stratification should guide a diagnostic strategy for the comprehensive evaluation and diagnosis of patients with this disorder.

The role of endobronchial ultrasound-guided transbronchial needle aspiration in mediastinal processes other than lung cancer

The role of endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration has expanded to include diseases other than lung cancer. In isolated mediastinal adenopathy with a low likelihood of lung cancer, EBUS has sensitivity of 92 %, and can prevent unnecessary mediastinoscopies. The procedure has an established use in sarcoidosis (overall diagnostic yield of 79 %) and in TB lymphadenitis with negative routine cultures. While the evidence in support of EBUS in lymphoma is not as robust, the technique may be used as a minimally invasive first-line diagnostic test. Novel roles for EBUS, such as the diagnosis of pulmonary thromboembolism, have also been described.

Thrombolytic treatment (alteplase; rt-Pa) in acute massive pulmonary embolism and cardiopulmonary arrest.

Patients with pulmonary thromboembolism (PE) often decompensate suddenly, and once hemodynamic compromise has developed, mortality is extremely high. Currently, thrombolytic therapy for PE is still controversial. We retrospectively evaluated 34 patients with PE between January 2010 and December 2013 in the Department of Pulmonary Medicine, Medical Park Samsun Hospital, Samsun, Turkey. The demographic and disease characteristics of patients who received thrombolytic treatment were retrospectively analyzed. The female to male ratio was 19/15 and the mean age was 63.1±13.2 years. PE diagnosis was made using echocardiography (64.7%) or contrast-enhanced thorax computed tomography with echocardiography (32.4%). Twenty-two (64.7%) patients went into the cardiopulmonary arrest due to massive PE and 17 (50%) patients recovered without sequelae. Eleven (32.4%) patients were diagnosed with massive PE during cardiopulmonary arrest with clinical and echocardiographic findings. Alteplase (recombinant tissue plasminogen activator [rt-PA]) was administered during cardiopulmonary resuscitation (CPR) and four (36.3%) patients responded and survived without sequelae. The complications of rt-PA treatment were hemorrhage in five (14.7%) patients and allergic reactions in two (5.9%) patients. There was no mortality due to rt-PA treatment complications. In conclusion, mortality due to massive PE is much more than estimated and alteplase can be used safely in patients with massive PE. This thrombolytic treatment was not associated with any fatal hemorrhage complication. If there is any sign of acute PE, echocardiography should be used during cardiopulmonary arrest/instability. Alteplase should be given to patients with suspected massive PE.

C0407: The Help of the Electrocardiogram in the Diagnosis of Pulmonary Thromboembolism

C0407: The Help of the Electrocardiogram in the Diagnosis of Pulmonary Thromboembolism

New onset right ventricular enlargement in recent dyspnea: Is echocardiography enough for a diagnosis of pulmonary thrombo-embolism?

Pulmonary embolism may be often promptly diagnosed just by bedside echocardiography, in the case of new onset severe right ventricular enlargement, increased pulmonary pressure and dyspnea. However, CT confirmation could be required in the presence of contrasting findings during diagnostic work up.We report the case of a 79-year old woman who presented with acute dyspnea, right ventricular enlargement and leftward septal shift. Despite first diagnosis of pulmonary embolism, an irregular mass was detected at CT scan in mid left lung, apparently infiltrating left pulmonary artery branches, without signs of evident pulmonary thrombo-embolism. Visceral pleural and lymphonodular infiltration suspected for malignancy was also present. We hypothesize that acutely increased pulmonary pressures and enlarged right ventricle were caused by the infiltrating pulmonary mass, presumably a lung tumor, partly involving left pulmonary artery branches and by tumor pulmonary embolism.A diagnosis of pulmonary thrombo-embolism exclusively based on echocardiography may be occasionally misleading without a careful diagnostic work-up.

Evaluation of serum endothelial cell specific molecule-1 (endocan) levels as a biomarker in patients with pulmonary thromboembolism

The aim of this study was to investigate the relationship between pulmonary thromboembolism (PTE) and serum endocan levels. The study included 46 patients with a diagnosis of PTE and control group (25 healthy individuals). Serum endocan levels in all participants' blood samples were measured. The average age of the individuals was 61.76 ± 16.39 years. There was a significant difference in the serum endocan levels between the patients and those of the control group [321.93 ng/l (111.35-2511.33) and 192.77 ng/l (118.30-309.02), respectively; P < 0.030]. The serum endocan levels in the submassive [469.41 ng/l (258.13-800.54)] and the massive PTE groups [719.18 ng/l (319.84-2511.33)] were statistically higher than those in the control group [192.77 ng/l (118.30-309.02)] (P < 0.001 and P < 0.001, respectively). In addition, there was a statistically significant difference between the serum endocan levels of the nonmassive PTE group [188.57 ng/l (111.35-685.56)] and the submassive PTE group (P < 0.01). The serum endocan levels correlated with the international normalization ratio (INR), right ventricular dilatation (RVD) and SBP (r = 0.418, P = 0.004; r = 0.659, P < 0.001; r = -0.425, P = 0.003, respectively). In conclusion, serum endocan levels can be considered a practicable biomarker to determine the severity of PTEs and follow-up thrombolytic therapy.

PP-342 Pulmonary Thromboembolism Diagnosed by Transthoracic Echocardiography in an Ulcerative Colitis Patient with Compound Heterozygous MTHFR C677T / MTHFR A1298C Mutations

Pulmonary embolism is a common problem in long term hospitalized, elderly and immobile patients and has high mortality rate if it’s not treated. Its diagnosis is sometimes very difficult. Hereditary factors, venous thromboembolism are important risk factor for these patients. Transthoracic echocardiography is a fast and noninvasive diagnostic method and used complementary to computed tomography, ventilation - perfusion scintigraphy and pulmonary angiography in the diagnosis of pulmonary thromboembolism.

Comparison of computed tomography pulmonary angiography and point‐of‐care tests for pulmonary thromboembolism diagnosis in dogs

ObjectivesTo evaluate the feasibility of CT pulmonary angiography for identification of naturally occurring pulmonary thromboembolism in dogs using predefined diagnostic criteria and to assess the ability of echocardiography, cardiac troponins, D-dimers and kaolin-activated thromboelastography to predict the presence of pulmonary thromboembolism in dogs.MethodsTwelve dogs with immune-mediated haemolytic anaemia and evidence of respiratory distress were prospectively evaluated. Dogs were sedated immediately before CT pulmonary angiography using intravenous butorphanol. Spiral CT pulmonary angiography was performed with a 16 detector-row CT scanner using a pressure injector to infuse contrast media through peripheral intravenous catheters. Pulmonary thromboembolism was diagnosed using predefined criteria. Contemporaneous tests included echocardiography, arterial blood gas analysis, kaolin-activated thromboelastography, D-dimers and cardiac troponins.ResultsBased on predefined criteria, four dogs were classified as pulmonary thromboembolism positive, three dogs were suspected to have pulmonary thromboembolism and the remaining five dogs had negative scans. The four dogs identified with pulmonary thromboembolism all had discrete filling defects in main or lobar pulmonary arteries. None of the contemporaneous tests was discriminant for pulmonary thromboembolism diagnosis, although the small sample size was limiting.Clinical SignificanceCT pulmonary angiography can be successfully performed in dogs under sedation, even in at-risk patients with respiratory distress and can both confirm and rule out pulmonary thromboembolism in dogs.

Strain imaging for evaluating response to thrombolytic therapy in pulmonary thromboembolism

Objective Patients with acute pulmonary thromboembolism (PTE) and right ventricular (RV) dysfunction may benefit from thrombolytic therapy. We sought to determine the usefulness of RV strain imaging in the demonstration of improvement in RV function in response to thrombolytic therapy.Methods This study prospectively enrolled 32 consecutive patients who received thrombolytic therapy due to diagnosis of PTE. The diagnosis was verified by 256-slice multi-detector computed tomography. Right ventricular function parameters were assessed via conventional and tissue Doppler imaging echocardiography before and 2-3 days after thrombolytic therapy.Results Echocardiographic study showed that mean tricuspid annular plane systolic excursion and RV fractional shortening area change increased significantly from 13.32 ± 3.46 mm to 18.18 ± 4.77 mm and from 22.95 ± 9.73% to 36.20 ± 10.17%, respectively, before compared to after treatment. A significant decrease was observed in systolic pulmonary artery pressure from 61.57 ± 10.49 mm Hg to 38.78 ± 14.27 mm Hg. Mid-ventricular peak systolic strain and strain rate of the RV also significantly improved (-6.08 ± 11.19% to -19.13 ± 9.51% and- 0.72 ± 0.96 S-1 to -1.54 ± 0.66 S-1, respectively).Conclusions Tissue Doppler-derived peak systolic strain of RV mid-ventricular wall may be potentially useful in the serial quantification of improvement in RV function in response to thrombolytic therapy in acute PTE.

Effect of Delay in Hospital Presentation on Clinical and Imaging Findings in Acute Pulmonary Thromboembolism

BackgroundThere is limited information on the extent and clinical importance of the delay in hospital presentation of acute pulmonary thromboembolism (PTE). ObjectiveThe aim of this study was to investigate the delay in hospital presentation of PTE and its association with clinical and imaging findings in PTE. MethodsThis prospective study was conducted on patients admitted to our hospital with a diagnosis of acute PTE between September 2007 and September 2011. Relationships between delay in hospital presentation and clinical findings, risk factors, imaging findings, and in-hospital mortality were analyzed. ResultsOf the 195 patients enrolled, 84 (43.1%) patients presented 3 days after the onset of symptoms. Patients with chest pain, history of immobility for more than 3 days, recent surgery, and estrogen use had significantly less delayed presentation. Right ventricular dysfunction was significantly more frequent in patients with delayed presentation (odds ratio [OR] = 2.38; 95% confidence interval [CI] 1.27−4.44; p = 0.006); however, no relationship was found between delay in presentation and pulmonary computed tomographic angiography or color Doppler sonography findings. Patients with delayed presentation were at higher risk of in-hospital mortality (OR = 4.32; 95% CI 1.12−16.49; p = 0.021). ConclusionsOur study showed that a significant portion of patients with acute PTE had delayed presentation. Also, patients with delayed presentation had worse echocardiographic findings and higher in-hospital mortality.

Application of rapid ultrasound in shock protocol in the ICU for management of shock.

Sir, One of the most challenging tasks in the Intensive Care Unit (ICU) is to rapidly determine the cause of shock in a critically ill patient and decide the most appropriate treatment in a short time. We describe a case of 34-year-old male with shock and impending respiratory failure presenting to ICU and its management based on information provided by rapid ultrasound in shock (RUSH) protocol. A 34-year-old male patient presented to the ICU with the complaints of recent onset severe dyspnea and dry cough. There was no history of chest pain, fever, and chest trauma. His physical examination revealed tachycardia (pulse rate: 112/min), tachypnea (respiratory rate: 48/min) and hypotension (blood pressure: 80/50 mmHg). Electrocardiogram showed sinus tachycardia, right axis deviation with S1Q3T3 pattern. Patient was intubated and mechanically ventilated in view of impending respiratory failure and shock. Along with initial resuscitation for the shock, she underwent ultrasound according to RUSH Protocol to evaluate the cause of shock. Pump: Grossly enlarged right atrium and right ventricle with D shaped left ventricle. McConnell's sign was present. Pulmonary artery was dilated with pulmonary artery systolic pressure 80 mm of Hg. Left ventricular contractility was adequate. There was no evidence of pericardial effusion or valvular dysfunction. Tank: Inferior vena cava was full and noncollapsing with respiration. Pipes: Deep venous thrombosis screening was done (femoral vein in the femoral canal, popliteal vein in popliteal fossa) which was normal. Screening of the aorta was also normal [Figure 1]. With this information, diagnosis of pulmonary thromboembolism (PTE) causing obstructive shock was considered. Computerized tomography based pulmonary angiography (CTPA) could not be as the patient was on the ventilator and hemodynamically unstable. We thrombolysed the patient with recombinant tissue-type plasminogen activator 100 mg intravenous infused over 90 min. SpO2 with subsequent improvement in hemodynamic parameters. Patient was gradually weaned off the ventilator by 5th day. Subsequently, CTPA showed embolism in the main and segmental branches of both pulmonary arteries. Figure 1 (a) ECG showing S1Q3T3 pattern (b) Chest x-ray showing Palla's sign (prominent right descending pulmonary artery) (c) Dilated right atria and ventricle (d) “D” shaped left ventricle (e and f) Non collapsible IVC seen on m mode (g) Femoral ... Rapid ultrasound in shock protocol is recently proposed systemic algorithm for evaluation of shock.[1] This protocol involves a three-step bedside sonographic assessment simplified as step 1: Evaluation of pump, step 2: Evaluation of tank, step 3: Evaluation of pipes [Table 1]. By focusing on both the anatomy and the physiology, points of care ultrasound by intensivists may help in differentiating between various etiologies of hypotension in the unstable patient. Characteristic ultrasonography finding facilitates the early diagnosis as well as provides prognostic information in PTE.[2,3] These findings needs to be interpreted in the context of the clinical picture as similar finding can be seen in chronic obstructive pulmonary disease, obstructive sleep apnea, pulmonary hypertension and right sided myocardial infarction. The relatively poor sensitivity of ultrasound findings necessitates other investigations to rule out the diagnosis of PTE in critically ill patients. Table 1 Rapid ultrasound in shock protocol: Ultrasonographic findings seen with classic shock states**