Pulmonary%20thromboembolism Signs and Symptoms

Pulmonary Embolism (PE)

• Blockage of one or more pulmonary arteries in the lungs usually due to blood clots from the veins, especially the veins, especially the veins in the legs & pelvis

Massive Pulmonary Embolism

• Acute PE w/ <90 mmHg systolic blood pressure (BP) for ≥15 minutes caused by PE which may or may not need inotropic therapy

Submassive Pulmonary Embolism

• Acute PE without systemic hypotension (≥90 mmHg systolic BP) accompanied by either right ventricular (RV) dysfunction or myocardial necrosis

• Suspicion of pulmonary embolism (PE) is usually raised by the clinical symptoms
• Dyspnea, pleuritic chest pain, tachypnea (respiratory rate ≥20 breaths/minute) occur in most cases of PE
  • Dyspnea is the most frequent symptom, while tachypnea is its most frequent sign
  • Other signs & symptoms that may be present: Tachycardia [heart rate (HR) >100 beats/minute (bpm)], cough, hemoptysis, syncope, nonpleuritic chest pain, wheezing, & hypotension
• Clinical instability or cardiac arrest is indicative of massive PE

Pleuritic Chest Pain

• Pleuritic chest pain w/ or without dyspnea is one of the most frequent presentations of PE
  • May suggest a small embolism located distally near the pleura

Isolated Dyspnea

• Isolated dyspnea may occur suddenly or progressively (over several weeks)
  • Usually due to a more central PE (not affecting the pleura)
  • May be associated w/ substernal angina-like chest pain that probably is representing right ventricular (RV) ischemia
  • Worsening dyspnea may be the only symptom that indicates PE in patients w/ preexisting heart failure (HF) or pulmonary disease

Syncope or Shock

• Syncope or shock are the hallmark signs of central PE & usually result in severe hemodynamic repercussions
  • Signs of hemodynamic compromise & reduced heart flow are also usually present (eg systemic arterial hypotension, oliguria, cold extremities &/or clinical signs of acute right heart failure)

Pulmonary Embolism (PE)

• Dyspnea is usually the prime symptom & systemic arterial hypotension that requires pressor support is the predominant sign
  • Hypotension is defined as a systolic BP <90 mmHg or a pressure drop of  ≥40 mmHg for >15 minutes if not caused by new-onset arrhythmia, hypovolemia, or sepsis
  • Syncope &/or cyanosis may be present

Massive Pulmonary Embolism (PE)

• Hemodynamic instability
  
  • SBP <100 mmHg, or SBP drop to 40 mmHg; HR >110 bpm
• Syncope
• Severe hypoxemia
• Respiratory distress

Venous Thromboembolism (VTE)

• The presence of risk factors for VTE in hypotensive patients should raise the possibility of pulmonary embolism (PE)
• The probability of PE increases w/ the number of risk factors present
• PE can also occur in individuals w/o risk factors
  

Primary Risk Factors

• Antithrombin deficiency
• Protein C deficiency
• Thrombomodulin
• Hyperhomocysteinemia
• Anticardiolipin antibody
• Prothrombin 20210A deficiency
• Factor XII deficiency
• Factor V Leiden (APC-R)
• Plasminogen deficiency
• Dysplasminogenemia
• Congenital dysfibrinogenemia
• Excessive plasminogen activator
• Protein S deficiency
• Positive history of proven VTE
• Trauma/fractures
  

Secondary Risk Factors

• Surgery
• Advanced age
• Central venous catheters
• HF
• Pregnancy/puerperium
• Hyperviscosity (polycythemia, Waldenstrom)
• Paresis
• Stroke
• Malignancy w/ or without chemotherapy
• Obesity
• Smoking
• Oral contraceptives (eg Estrogen)
• Prosthetic surfaces
• Platelet abnormalities
• Congenital heart disease
• Hypertension
• Chronic venous insufficiency
• Long distance travel
• Crohn’s disease
• Lupus anticoagulant
• Nephrotic syndrome