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Written by Administrator
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Thursday, 08 October 2009 04:13 |
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Time: usually 7:10 days after pelvic operation or labour.
Cause: Detached thrombosis of deep veins.
Types:
1- Fatal type: Sudden death. Obstruction of main trunk.
2- Massive type: obstruction of main branch leading to sudden severe chest pain with dyspnea, cyanosis and hypotension. If not treated rapidly thrombosis may extend to occlude the main trunk causing death in few hours.
3- Pulmonary infarction: obstruction of small branch leading to severe chest pain , dyspnea and haemoptysis.
4- Recurrent emboli (showers of emboli) multiple minute infarction. It gives the same clinical picture of pulmonary infarction but milder.
Investigations:
Once diagnosis is suspected full therapeutic dose of heparin should be given and the patient should be transferred to intensive care unit. The following investigations can help to confirm diagnosis
Diagnosis:
I. Investigations to exclude or support an alternative diagnosis:
a- Arterial blood gas (ABG) analysis,
b- Electrocardiography (ECG)
c- Chest radiograph.
II. Investigations aimed at diagnosing PE
a- D-dimer blood testing
b- Ventilation perfusion lung scanning (V/Q). Normal V/Q scan generally excludes PE but it is only found I 25% of patients without PE. Increased number and sizes of the defects, presence of wedge shape and the presence of normal ventilation (Mismatched defect) all with diagnosis of PE.
c- CT Pulmonary Angiography: It allows for direct visualization of emboli, as well as lung parenchymal abnormalities.
d- Pulmonary Angiography: It is the gold-standard for diagnosis of PE. Although safe it requires expertise in performance and interpretation and is invasive. It is also more time consuming than CT. It is also not readily available in many centers.
Treatment:
The patient should be transferred to ICU
Ø Anticoagulants, Heparine infusion and oral anticoagulant with the same dosage and protocol discussed before in treatment of DVT.
Ø Positive pressure ventilation and correction of hypotension.
Ø Thrombolytics: The same drugs as discussed in treatment of DVT. It may give rapid improvement but with more bleeding complications and follow up studies found no benefit of its use. In haemodynamically unstable patients thrombolytics are a consideration.
Surgical:
1- Percutaeneous filter implantation into the I.V.C. It is indicated in the following situation:
a. Patients have contraindications to anticoagulation
b. Patients not responding to anticoagulants.
c. Patients who develop recurrent PE despite adequate anticoagulation
2- Pulmonary embolectomy in massive type with hyoptension may be life saving.
Fat embolism:
1- Usually follow Fracture femur or burn.
2- It cause cerebral & Pulmonary irritation.
3- Na desoxylate may dissolve the thrombus.
Air embolism:
1- Systemic type: during I.V. infusion or neck operation.
2- Cerebal type: In chest operation.
SOURCE: DR AYMAN SALEM'S BOOK
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Last Updated on Friday, 09 October 2009 06:34 |
