Imaging: Pulmonary Embolism

Image of the weekJagdish K

Prof. Dr. A Gowrishankar’s unitm3

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.

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

Chest X ray

ECG

exudative

60 lymphocytes/cumm

6 mesothelial cells/cumm

Ada – 16 iu/l

Pleural fluid analysis

700ng/ml

D dimer

CT Chest

“ Few health care providers realise the case fatality rates for pulmonary embolism is 15%, exceeds that of acute MI”

Pulmonary embolism

Risk factors

Inherited

Acquired

Thrombophilias

Endotelial injury

Stasis

Hypercoagulablility

Virchow’s Triad

Most common symptoms & signs

Well’s clinical decision rule

Mild Moderate Severe Paradoxical Pulmonary infarction syndrome Nonthrombotic pulmonary embolism

Diverse clinical scenarios

Pulmonary infarction syndrome

Oxygen saturation

Chest x ray

D dimer

Investigations

ECG changes

Echocardiographic changes

Multidetector CT – The one stop shop

CT Angiography

CT PULMONARY ANGIOGRAM

Lung scanning

Pulmonary angiography

Venous ultrasound

MRI

continued

Clinical predictors of increased mortality

Biomarkers & imaging predictors of increased mortality

Approach to the patient

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

“Can also occur concomitantly with other illnesses , thereby confounding the diagnostic work up”

“ 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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