Pulmonary embolism

Pulmonary embolism

Contents of the post

  • Overview
  • Causes
  • Symptoms
  • Diagnosis
  • Prevention
  • Treatment
  • Prognosis
  • Factors which predisposes a person  to blood clots
  • References and further reading

Overview

Pulmonary embolism is the sudden blocking of an artery of the lung, also known as pulmonary artery, by a embolus – a blood clot or a thrombus.

  • The functions of the arteries of the lungs are to carry enough blood containing oxygen and nutrients to keep the lung tissue healthy and to carry carbon dioxide to the lungs for removal from the body.
  • But, when a large artery to the lung is blocked by an embolus, the amount of blood supplied may be insufficient, eventually causing lung tissue to die.
  • About 10% of people suffering from pulmonary embolism suffer some lung tissue death, which is also called pulmonary infarction.
  • Sometimes the body breaks the small clots quickly, keeping damage to a minimum.
  • Large clots take much longer to disintegrate, so more damage is done.
  • Large clots may cause sudden death by blocking so much of the lung arteries that the oxygen supply to the body is inadequate to sustain life or by placing an excessive strain on the heart.
  • The prevalence of pulmonary embolism in people admitted to the hospital is about 1%.
  • When an autopsy is performed, pulmonary embolism is often unexpectedly found to be the cause of death in about 5% of the people.

Causes

  • The most common type of embolus that travels to the lungs is a blood clot, usually, one that forms in a leg or a pelvic vein when blood flow slows down or stops, as may occur in leg veins when a person stays in one position for a long time.
  • People who have been on prolonged bed rest and those sitting for long periods without moving around (as may happen during air travel) are at particular risk.
  • When the person starts moving again, the clot can break loose.
  • Far less often, blood clots form in the veins of the arm or in the right side of the heart. Once a clot breaks free into the bloodstream; it usually travels to the lungs.
  • Another type of embolus may form from fat, which can escape into the blood from bone marrow when a bone is fractured.
  • An embolus may also form from the amniotic fluid being forced into the pelvic veins during childbirth.
  • However, both fat and amniotic emboli are rare. If they form, they usually lodge in small vessels like arterioles and capillaries of the lungs, where they generally cause less damage than the blood clots.
  • However, if many of these blood vessels are obstructed, acute respiratory distress syndrome or pulmonary hypertension may develop. Both of these conditions can lead to respiratory failure, heart failure and shock.
  • Cancerous tumor fragments can break into the circulation to form emboli, which, if they are numerous, can cause pulmonary hypertension as the cancer spreads throughout the lungs.
  • Air bubbles may form an emboli and cause pulmonary embolism after a vein has been exposed to large amounts of air, as may occur during intravenous infusion of drugs, nutrients or fluid.
  • Air emboli may also form when a vein is being operated on or when a person is being resuscitated.
  • An additional risk is when a person dives underwater and the risk depends upon how deep he dives and how fast he ascends to the surface of the water.

Symptoms

  • Symptoms depend upon the extent to which the pulmonary artery is blocked and on the person’s overall health.
  • For example, people who have other diseases such as chronic obstructive pulmonary disease or coronary artery disease, may have more disabling symptoms.
  • Small emboli may not cause any symptoms.
  • Most emboli cause shortness of breath which comes on very quickly.
  • Shortness of breath may be the only symptom especially if pulmonary infarction does not develop.
  • Often the breathing is very rapid and a person feels anxious or restless and appears to have an anxiety attack.
  • Larger emboli commonly cause sharp pain in the chest especially when the person inhales. This type of pain is called pleuritic chest pain.
  • In some people, the first symptoms of pulmonary embolism may be light headedness, fainting or seizures.
  • These symptoms usually result from a sudden decrease in the heart’s ability to deliver enough oxygen-rich blood to the brain and other organs.
  • People with obstruction of one or more large pulmonary arteries, have a blue skin colour and can die suddenly.
  • The symptoms of pulmonary embolism develop abruptly, whereas the symptom of pulmonary infarction develops over the following hours.
  • If pulmonary infarction occurs, the person experience soughing that may produce blood-stained sputum, sharp chest pain when the person breathes in and in some cases, fever.
  • Symptoms of infarction often last several days but usually become milder every day.
  • In people who have recurring episodes of pulmonary emboli, symptoms such as chronic shortness of breath, swelling of the ankles or legs, and weakness tend to develop progressively over weeks, months or years.

Diagnosis

  • A doctor suspects pulmonary embolism based on the person’s symptoms and predisposing factors, such as a recent surgery or a prolonged period of bed rest.
  • A large pulmonary embolism may be relatively easy for a doctor to diagnose, especially when there are obvious preconditions, such as signs of a blood clot in a leg.
  • Certain procedures are often needed to confirm the diagnosis.
  • Even with these procedures, however, many emboli can be quite subtle and difficult for doctors to diagnose conclusively.
  • A chest X-ray may reveal subtle changes in the blood vessel patterns after embolism and signs of pulmonary infarction.
    • However, the results are often normal and even when they are abnormal; they rarely enable the doctor to establish the diagnosis with certainty.
  • An electrocardiogram may show abnormalities, but often these abnormalities are transient and can only support the possibility of a pulmonary embolism.
  • A lung perfusion scan is one of the best tests for diagnosing pulmonary embolism.
    • In this test, a tiny amount of radioactive substance is injected into a vein and travels to the lungs, where it outlines the blood supply of the lungs.
    • Areas without normal blood supply appear dark on the scan because no radioactive particles can reach them.
    • Normal scan results indicate that a person does not have significant blood vessel obstruction.
    • Abnormal scan results support the possibility of pulmonary embolism but may also reflect conditions other than pulmonary embolism, such as obstructive lung disease.
  • A lung ventilation scan is usually coupled with perfusion scan.
    • The person inhales a harmless gas containing a trace amount of radioactive material which is distributed throughout the small air sacs of the lungs.
    • The areas where carbon dioxide is being released and oxygen taken up can then be seen on a scanner.
    • By comparing this scan to the pattern of blood supply shown on the perfusion scan, a doctor can usually determine whether a person has had a pulmonary embolism by a mismatch between ventilation and blood perfusion.
  • Pulmonary angiography is an accurate means of diagnosing pulmonary embolism, but it poses some risks and is more uncomfortable than the other tests.
    • It is only performed only when other tests fail to demonstrate a conclusive diagnosis of pulmonary embolism.
  • In an X-ray procedure, a radiopaque dye is injected into the pulmonary arteries.
    • A pulmonary embolism shows up as blockage in an artery.
  • A certain type of computed tomography (CT) called CT angiography is another accurate test.
    • CT angiography can be used if pulmonary angiography is not available or if the person should not undergo this test for some reason.
  • Additional tests such as an ultrasound to examine the legs for blood clots in the veins may be performed to find out where the embolus originally developed.
  • A blood test (D dimer test) can provide additional support of the diagnosis.
  • A normal test result can help to exclude pulmonary embolism as the cause of a person’s symptoms.

Prevention

  • Given the dangers of pulmonary embolism and limitations of treatment, doctors try to prevent blood clots from forming in the veins of people at risk of pulmonary embolism.
  • In general, a person who is prone to clotting should try to be active and move around as much as possible.
    • For example, when traveling on an airplane for a long period, the person should try to get up and move around every two hours.
  • For people who have undergone surgery, especially the older people, the risk of clot formation can be reduced by the following measures :
    • Wearing compression elastic stockings
    • Doing leg exercises
    • Getting out of bed and becoming active as soon as possible.
  • For people who cannot move their legs, intermittent air compression devices can provide rhythmic external pressure to keep the blood moving in legs and thighs.
  • However, these devices alone are inadequate to prevent clot formation in people who have undergone hip or knee surgery.
  • Anticoagulant drugs are given.
    • Heparin is the most widely used therapy for reducing the likelihood of clots formation in calf veins after any type of major surgery, especially surgery for the legs.
    • Hospitalized people at high risk of developing pulmonary embolism, benefit from small doses of heparin even if they are not undergoing surgery.
    • Small doses are injected just under the skin shortly before the operation and ideally until the person is up and walking again.
    • Low dose heparin does not increase the frequency of major bleeding complications, but heparin can increase minor oozing of blood from wounds.
    • Low-dose heparin can also be used for operations involving the spine or brain.
    • A different form of heparin called low molecular weight heparin, is equally or even more effective in preventing clots than the use of traditional heparin.
    • Low molecular weight heparin is also injected just under the skin and is usually continued until the risk of developing clots has passed.
    • Warfarin is given when a person has undergone certain types of surgery that are particularly likely to result in clots, such as surgery for a hip fracture or a joint replacement.
    • Warfarin therapy may need to be continued for weeks or months.
    • Low molecular weight heparin is also effective for people in this situation.

Treatment

  • Treatment of pulmonary embolism begins with the administration of oxygen and if necessary, analgesics are given to relieve pain.
  • Anti-coagulant drugs such as heparin are given to prevent the existing blood clots from enlarging and additional clots from forming.
  • Heparin is given intravenously to achieve a rapid effect, and doctors carefully regulate the dose.
  • Doctors strive to achieve a full effect within the first 24 hours of treatment.
    • Otherwise, the person is at high risk of more pulmonary emboli and new clots or enlargement of existing clots in leg and pelvic veins.
  • Low molecular weight heparin is probably equally effective to traditional heparin and does not require the blood test monitoring that conventional heparin requires.
  • Warfarin is given next. It inhibits clotting but it takes longer to start working. In other words, it has delayed onset of action.
    • Also, since warfarin is taken by mouth, it can be used long-term.
  • Heparin and warfarin are given together for 5 to 7 days, until blood tests show that warfarin is effectively preventing clotting. Then, heparin is discontinued.
  • The duration for which anti-coagulants are given to a person depends upon the person’s situation.
  • If pulmonary embolism is caused by temporary predisposing factor, such as surgery, treatment is given for 2 to 3 months.
  • If the cause is some long-term problem, such as prolonged bed rest, treatment is given for 3 to 6 months. In certain cases, treatment must continue indefinitely.
    • For example, people who have recurrent pulmonary embolism, often due to a hereditary predisposition to clotting, usually take anticoagulants indefinitely.
    • While taking warfarin, the person periodically has to have a blood test to determine if the dose needs to be adjusted. Changes in diet and many other drugs may affect the magnitude of anticoagulation by this drug.
    • If excessive anticoagulation occurs, severe bleeding in a number of body organs can develop.
  • Thrombolytic therapy appears to be in danger of dying of pulmonary embolism.
  • Thrombolytic drugs such as streptokinase or tissue plasminogen activator break up and dissolve the clot.
  • However, these drugs cannot be given to people who have had surgery in the preceding 2 weeks, are pregnant and have had a recent stroke or tend to bleed excessively.
  • Surgery may be needed to save someone with severe embolism.
    • Removal of the embolus from the pulmonary artery may be lifesaving.
  • Surgery is also used to remove long standing pulmonary clots in the artery that cause persistent shortness of breath and pulmonary hypertension.
  • A filter can be surgically placed in the main vein in the abdomen that drains blood from the legs and pelvis to the right side of the heart.
    • Such a filter can be used if emboli recur despite anticoagulant treatment or if anticoagulants cannot be used or cause significant bleeding.
    • Because clots generally originate in the legs and pelvis, this filter usually prevents them from being carried into the pulmonary artery.
  • For emboli that form from fat or amniotic fluid, oxygen therapy and use of ventilator may be needed.
  • In addition, emboli that develop from amniotic fluid may stimulate the formation of blood clots; agents such as cryoprecipitate are sometimes needed to block certain key steps in the formation of these clots.
    • For example, blocking the formation of fibrin deposits in the circulation.

Prognosis

  • About half of the people with untreated pulmonary embolism will have another embolism.
  • As many as half of these recurrences may be fatal.
  • Treatment with anticoagulant drugs can reduce the rate of recurrence to about 1 in 20 people.
    • Only about 1 in 5 of these people will die of pulmonary embolism.
  • The likelihood of dying depends upon:
    • The size of the embolus
    • Size of the pulmonary artery that is blocked
    • Number of the pulmonary arteries blocked
    • Person’s overall health status
  • Anyone with a serious heart or lung problem is at a greater risk of dying from pulmonary embolism.
  • A person with normal heart and lung function usually survives unless the embolus blocks half or more of the pulmonary vessels.
  • If death occurs from pulmonary embolism, it occurs rapidly often within 1 to 2 hours.
  • An air embolism can cause death, but only if the amount of air that reaches the heart and pulmonary arteries is large.
  • Death occurs with a large air embolus not only because blood flow to much of the lungs is blocked, but also because heart cannot effectively pump blood.

Factors which predisposes a person to blood clots

  • Advanced age
  • Heart attack
  • Blood clotting disorder
  • Cancer
  • Heart failure
  • Major surgery
  • Irregular heartbeat or atrial fibrillation
  • Obesity
  • Prior blood clot
  • Paralysis
  • Pelvis, hip or leg fracture
  • Stroke
  • Prolonged bed rest or inactivity
  • Use of oral contraceptives (especially after 35 or in someone who smokes)

wikipedia

Click here to go to lung disorders forums.

  • “What Are the Signs and Symptoms of Pulmonary Embolism?”. NHLBI. July 1, 2011. Archived from the original on 9 March 2016. Retrieved 12 March 2016.
  •  Goldhaber SZ (2005). “Pulmonary thromboembolism”. In Kasper DL, Braunwald E, Fauci AS, et al. Harrison’s Principles of Internal Medicine (16th ed.). New York, NY: McGraw-Hill. pp. 1561–65. ISBN 0-07-139140-1.
  •  “Who Is at Risk for Pulmonary Embolism?”. NHLBI. July 1, 2011. Archived from the original on 15 February 2016. Retrieved 12 March 2016.
  •  “How Is Pulmonary Embolism Diagnosed?”. NHLBI. July 1, 2011. Archived from the original on 7 April 2016. Retrieved 12 March 2016.
  •  “How Is Pulmonary Embolism Treated?”. NHLBI. July 1, 2011. Archived from the original on 9 March 2016. Retrieved 12 March 2016.
  •  “What Is Pulmonary Embolism?”. NHLBI. July 1, 2011. Archived from the original on 12 March 2016. Retrieved 12 March 2016.
  •  Rahimtoola A, Bergin JD (February 2005). “Acute pulmonary embolism: an update on diagnosis and management”. Current problems in cardiology. 30 (2): 61–114. doi:10.1016/j.cpcardiol.2004.06.001. PMID 15650680.
  •  Raskob, GE; Angchaisuksiri, P; Blanco, AN; Buller, H; Gallus, A; Hunt, BJ; Hylek, EM; Kakkar, A; Konstantinides, SV; McCumber, M; Ozaki, Y; Wendelboe, A; Weitz, JI; ISTH Steering Committee for World Thrombosis, Day (November 2014). “Thrombosis: a major contributor to global disease burden”. Arteriosclerosis, Thrombosis, and Vascular Biology. 34 (11): 2363–71. doi:10.1161/atvbaha.114.304488. PMID 25304324.
  •  Kumar V, Abbas AK, Fausto N, Mitchell RN (2010). Basic Pathology. New Delhi: Elsevier. p. 98. ISBN 978-81-312-1036-9.
  •  Tintinalli, Judith E. (2010). Emergency Medicine: A Comprehensive Study Guide (Emergency Medicine (Tintinalli)) (7 ed.). New York: McGraw-Hill Companies. p. 432. ISBN 0-07-148480-9.
  •  “What Causes Pulmonary Embolism?”. NHLBI. July 1, 2011. Archived from the original on 7 April 2016. Retrieved 12 March 2016.
  •  Pantaleo, G; Luigi, N; Federica, T; Paola, S; Margherita, N; Tahir, M (2014). “Amniotic fluid embolism: review”. Current pharmaceutical biotechnology. 14 (14): 1163–7. doi:10.2174/1389201015666140430161404. PMID 24804726.
  •  “Other Names for Pulmonary Embolism”. July 1, 2011. Archived from the original on 16 March 2016. Retrieved 12 March 2016.
  •  “How Can Pulmonary Embolism Be Prevented?”. NHLBI. July 1, 2011. Archived from the original on 7 April 2016. Retrieved 12 March 2016.
  •  “Living With Pulmonary Embolism”. July 1, 2011. Archived from the original on 7 April 2016. Retrieved 12 March 2016.
  •  Lewis, S; Dirksen, S; Heitkemper, M; Bucher, L (2014). Medical-surgical nursing: Assessment and management of clinical problems (9 ed.). St. Louis, MO: Elsevier Mosby. p. 552. ISBN 978-0-323-08678-3.
  •  Oqab, Z; Ganshorn, H; Sheldon, R (April 2018). “Prevalence of pulmonary embolism in patients presenting with syncope. A systematic review and meta-analysis”. The American journal of emergency medicine. 36 (4): 551–555. doi:10.1016/j.ajem.2017.09.015. PMID 28947223.
  •  Stein PD, Sostman HD, Hull RD, Goodman LR, Leeper KV, Gottschalk A, Tapson VF, Woodard PK (March 2009). “Diagnosis of Pulmonary Embolism in the Coronary Care Unit”. Am. J. Cardiol. 103 (6): 881–6. doi:10.1016/j.amjcard.2008.11.040. PMC 2717714 Freely accessible. PMID 19268750.
  •  Pregerson DB, Quick Essentials: Emergency Medicine, 4th edition. EMresource.org
  •  Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, Jenkins JS, Kline JA, Michaels AD, Thistlethwaite P, Vedantham S, White RJ, Zierler BK (Apr 26, 2011). American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, American Heart Association Council on Peripheral Vascular Disease, American Heart Association Council on Arteriosclerosis, Thrombosis, and Vascular Biology. “Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association”. Circulation. 123 (16): 1788–830. doi:10.1161/CIR.0b013e318214914f. PMID 21422387.
  •  Ferri, F (2012). Ferri’s Clinical Advisor. St. Louis: Mosby’s.
  •  “Pulmonary embolus”. MedlinePlus Medical Encyclopedia. Archived from the original on 25 April 2017. Retrieved 24 April 2017.
  •  American College of Radiology. “Five Things Physicians and Patients Should Question” (PDF). Choosing Wisely: an initiative of the ABIM Foundation. American College of Radiology. Archived (PDF) from the original on April 16, 2012. Retrieved August 17, 2012.
  •  Raja, AS; Greenberg, JO; Qaseem, A; Denberg, TD; Fitterman, N; Schuur, JD (29 September 2015). “Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians”. Annals of Internal Medicine. 163: 701–11. doi:10.7326/M14-1772. PMID 26414967.
  •  Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, Sos TA, Quinn DA, Leeper KV, Hull RD, Hales CA, Gottschalk A, Goodman LR, Fowler SE, Buckley JD (2007). “Diagnostic Pathways in Acute Pulmonary Embolism: Recommendations of the PIOPED II Investigators”. Radiology. 242 (1): 15–21. doi:10.1148/radiol.2421060971. PMID 17185658.
  •  Authors/Task Force, Members; Konstantinides, SV; Torbicki, A; Agnelli, G; Danchin, N; Fitzmaurice, D; Galiè, N; Gibbs, JS; Huisman, MV; Humbert, M; Kucher, N; Lang, I; Lankeit, M; Lekakis, J; Maack, C; Mayer, E; Meneveau, N; Perrier, A; Pruszczyk, P; Rasmussen, LH; Schindler, TH; Svitil, P; Vonk Noordegraaf, A; Zamorano, JL; Zompatori, M; Authors/Task Force, Members (Aug 29, 2014). “2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC) Endorsed by the European Respiratory Society (ERS)”. European Heart Journal. 35: 3033–3073. doi:10.1093/eurheartj/ehu283. PMID 25173341.
  •  Wells PS, Hirsh J, Anderson DR, Lensing AW, Foster G, Kearon C, Weitz J, D’Ovidio R, Cogo A, Prandoni P (1995). “Accuracy of clinical assessment of deep-vein thrombosis”. Lancet. 345 (8961): 1326–30. doi:10.1016/S0140-6736(95)92535-X. PMID 7752753.
  •  Wells PS, Ginsberg JS, Anderson DR, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J (1998). “Use of a clinical model for safe management of patients with suspected pulmonary embolism”. Ann Intern Med. 129 (12): 997–1005. doi:10.7326/0003-4819-129-12-199812150-00002. PMID 9867786.
  •  Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J (2000). “Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer”. Thromb Haemost. 83 (3): 416–20. PMID 10744147.
  •  Wells PS, Anderson DR, Rodger M, Stiell I, Dreyer JF, Barnes D, Forgie M, Kovacs G, Ward J, Kovacs MJ (2001). “Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer”. Ann Intern Med. 135 (2): 98–107. doi:10.7326/0003-4819-135-2-200107170-00010. PMID 11453709.
  •  Sanson BJ, Lijmer JG, Mac Gillavry MR, Turkstra F, Prins MH, Büller HR (2000). “Comparison of a clinical probability estimate and two clinical models in patients with suspected pulmonary embolism. ANTELOPE-Study Group”. Thromb. Haemost. 83 (2): 199–203. PMID 10739372.
  •  van Belle A, Büller HR, Huisman MV, Huisman PM, Kaasjager K, Kamphuisen PW, Kramer MH, Kruip MJ, Kwakkel-van Erp JM, Leebeek FW, Nijkeuter M, Prins MH, Sohne M, Tick LW (2006). “Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography”. JAMA. 295 (2): 172–9. doi:10.1001/jama.295.2.172. PMID 16403929. Archived from the original on 2007-02-11.
  •  Roy PM, Meyer G, Vielle B, Le Gall C, Verschuren F, Carpentier F, Leveau P, Furber A (2006). “Appropriateness of diagnostic management and outcomes of suspected pulmonary embolism”. Ann. Intern. Med. 144 (3): 157–64. doi:10.7326/0003-4819-144-3-200602070-00003. PMID 16461959.
  •  Neff MJ (2003). “ACEP releases clinical policy on evaluation and management of pulmonary embolism”. American Family Physician. 68 (4): 759–60. PMID 12952389. Archived from the original on 2007-09-26.
  •  Yap KS, Kalff V, Turlakow A, Kelly MJ (2007). “A prospective reassessment of the utility of the Wells score in identifying pulmonary embolism”. Med. J. Aust. 187 (6): 333–6. PMID 17874979.
  •  Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, Sos TA, Quinn DA, Leeper KV, Hull RD, Hales CA, Gottschalk A, Goodman LR, Fowler SE, Buckley JD (2007). “Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II Investigators”. Radiology. 242 (1): 15–21. doi:10.1148/radiol.2421060971. PMID 17185658.
  •  van Es, N; van der Hulle, T; Büller, HR; Klok, FA; Huisman, MV; Galipienzo, J; Di Nisio, M (22 November 2016). “Is stand-alone D-dimer testing safe to rule out acute pulmonary embolism?”. Journal of thrombosis and haemostasis : JTH. 15: 323–328. doi:10.1111/jth.13574. PMID 27873439.
  •  Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM (2004). “Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism”. Journal of Thrombosis and Haemostasis. 2 (8): 1247–55. doi:10.1111/j.1538-7836.2004.00790.x. PMID 15304025.
  •  Kline JA, Courtney DM, Kabrhel C, Moore CL, Smithline HA, Plewa MC, Richman PB, O’Neil BJ, Nordenholz K (2008). “Prospective multicenter evaluation of the pulmonary embolism rule-out criteria”. Journal of Thrombosis and Haemostasis. 6 (5): 772–780. doi:10.1111/j.1538-7836.2008.02944.x. PMID 18318689. Archived from the original on 2011-06-07.
  •  Carrier M, Righini M, Djurabi RK, Huisman MV, Perrier A, Wells PS, Rodger M, Wuillemin WA, Le Gal G (May 2009). “VIDAS D-dimer in combination with clinical pre-test probability to rule out pulmonary embolism. A systematic review of management outcome studies”. Thromb. Haemost. 101 (5): 886–92. doi:10.1160/TH-08-10-0689. PMID 19404542.
  •  Schrecengost JE, LeGallo RD, Boyd JC, Moons KG, Gonias SL, Rose CE, Bruns DE (September 2003). “Comparison of diagnostic accuracies in outpatients and hospitalized patients of D-dimer testing for the evaluation of suspected pulmonary embolism”. Clin. Chem. 49 (9): 1483–90. doi:10.1373/49.9.1483. PMID 12928229. Archived from the original on 2010-12-06.
  •  Schouten HJ, Geersing GJ, Koek HL, Zuithoff NP, Janssen KJ, Douma RA, van Delden JJ, Moons KG, Reitsma JB (May 3, 2013). “Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis”. BMJ (Clinical research ed.). 346: f2492. doi:10.1136/bmj.f2492. PMC 3643284 Freely accessible. PMID 23645857.
  •  van Es, N; van der Hulle, T; van Es, J; den Exter, PL; Douma, RA; Goekoop, RJ; Mos, IC; Galipienzo, J; Kamphuisen, PW; Huisman, MV; Klok, FA; Büller, HR; Bossuyt, PM (16 August 2016). “Wells Rule and d-Dimer Testing to Rule Out Pulmonary Embolism: A Systematic Review and Individual-Patient Data Meta-analysis”. Annals of Internal Medicine. 165 (4): 253–61. doi:10.7326/m16-0031. PMID 27182696.
  •  Söhne, Maaike; Ten Wolde, Marije; Büller, Harry R. (1 November 2004). “Biomarkers in pulmonary embolism”. Current Opinion in Cardiology. 19 (6): 558–562. doi:10.1097/01.hco.0000138991.82347.0e. ISSN 0268-4705. PMID 15502498.
  •  Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP (2008). “Guidelines on the diagnosis and management of acute pulmonary embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)”. European Heart Journal. 29 (18): 2276–2315. doi:10.1093/eurheartj/ehn310. PMID 18757870.
  •  Stein PD, Freeman LM, Sostman HD, Goodman LR, Woodard PK, Naidich DP, Gottschalk A, Bailey DL, Matta F, Yaekoub AY, Hales CA, Hull RD, Leeper KV, Tapson VF, Weg JG (2009). “SPECT in acute pulmonary embolism”. J Nucl Med (Review). 50 (12): 1999–2007. doi:10.2967/jnumed.109.063958. PMID 19949025. Archived from the original on 2017-09-08.
  •  Konstantinides, S; Torbicki, A; Agnelli, G; Danchin, N; Fitzmaurice, D; Galiè, N; Gibbs, JSR; Huisman, M; Humbert, M; Kucher, N (14 November 2014). “2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism”. European Heart Journal. 35 (43): 3033–3069. doi:10.1093/eurheartj/ehu283. PMID 25173341. Archived from the original on 16 November 2016. Pulmonary angiography has for decades remained the ‘gold standard’ for the diagnosis or exclusion of PE, but is rarely performed now as less-invasive CT angiography offers similar diagnostic accuracy.
  •  Da Costa Rodrigues, J; Alzuphar, S; Combescure, C; Le Gal, G; Perrier, A (5 July 2016). “Diagnostic characteristics of lower limb venous compression ultrasonography in suspected pulmonary embolism: a meta-analysis”. Journal of thrombosis and haemostasis : JTH. 14: 1765–72. doi:10.1111/jth.13407. PMID 27377039.
  •  Schaefer-Prokop C, Prokop M (2005). “MDCT for the diagnosis of acute pulmonary embolism”. European radiology. 15 (Suppl 4): D37–41. doi:10.1007/s10406-005-0144-3. PMID 16479644.
  •  Van Strijen MJ, De Monye W, Kieft GJ, Pattynama PM, Prins MH, Huisman MV (2005). “Accuracy of single-detector spiral CT in the diagnosis of pulmonary embolism: a prospective multicenter cohort study of consecutive patients with abnormal perfusion scintigraphy”. Journal of thrombosis and haemostasis : JTH. 3 (1): 17–25. doi:10.1111/j.1538-7836.2004.01064.x. PMID 15634261.
  •  Stein PD, Fowler SE, Goodman LR, Gottschalk A, Hales CA, Hull RD, Leeper KV, Popovich J, Quinn DA, Sos TA, Sostman HD, Tapson VF, Wakefield TW, Weg JG, Woodard PK (2006). “Multidetector computed tomography for acute pulmonary embolism”. N. Engl. J. Med. 354 (22): 2317–27. doi:10.1056/NEJMoa052367. PMID 16738268.
  •  Anderson DR, Kahn SR, Rodger MA, Kovacs MJ, Morris T, Hirsch A, Lang E, Stiell I, Kovacs G, Dreyer J, Dennie C, Cartier Y, Barnes D, Burton E, Pleasance S, Skedgel C, O’Rouke K, Wells PS (2007). “Computed tomographic pulmonary angiography vs ventilation-perfusion lung scanning in patients with suspected pulmonary embolism”. JAMA. 298 (23): 2743–53. doi:10.1001/jama.298.23.2743. PMID 18165667.
  •  Scarsbrook AF, Gleeson FV (2007). “Investigating suspected pulmonary embolism in pregnancy”. BMJ. 334 (7590): 418–9. doi:10.1136/bmj.39071.617257.80. PMC 1804186 Freely accessible. PMID 17322258. Archived from the original on 2007-09-04.
  •  Leung AN, Bull TM, Jaeschke R, Lockwood CJ, Boiselle PM, Hurwitz LM, James AH, McCullough LB, Menda Y, Paidas MJ, Royal HD, Tapson VF, Winer-Muram HT, Chervenak FA, Cody DD, McNitt-Gray MF, Stave CD, Tuttle BD (2011-11-15). “An official American Thoracic Society/Society of Thoracic Radiology clinical practice guideline: evaluation of suspected pulmonary embolism in pregnancy”. American Journal of Respiratory and Critical Care Medicine. 184 (10): 1200–8. doi:10.1164/rccm.201108-1575ST. PMID 22086989.
  •  Thomson, AJ; Greer, IA (April 2015). “Thrombosis and Embolism during Pregnancy and the Puerperium, the Acute Management of (Green-top Guideline No. 37b)”. Royal College of Obstetricians & Gynaecologists. Retrieved 4 June 2018.
  •  Worsley DF, Alavi A, Aronchick JM, Chen JT, Greenspan RH, Ravin CE (1993). “Chest radiographic findings in patients with acute pulmonary embolism: observations from the PIOPED Study”. Radiology. 189 (1): 133–6. doi:10.1148/radiology.189.1.8372182. PMID 8372182.
  •  Brown G, Hogg K (October 2005). “Best evidence topic report. Diagnostic utility of electrocardiogram for diagnosing pulmonary embolism”. Emergency medicine journal : EMJ. 22 (10): 729–30. doi:10.1136/emj.2005.029041. PMC 1726554 Freely accessible. PMID 16189038.
  •  Mattu, edited by Amal; Goyal, Deepi (2007). Emergency medicine avoiding the pitfalls and improving the outcomes. Malden, Mass.: Blackwell Pub./BMJ Books. p. 9. ISBN 9780470755174. Archived from the original on 2017-09-08.
  •  McGinn S, White PD (1935). “Acute cor pulmonale resulting from pulmonary embolism”. J Am Med Assoc. 104 (17): 1473–80. doi:10.1001/jama.1935.02760170011004.
  •  Rodger M, Makropoulos D, Turek M, Quevillon J, Raymond F, Rasuli P, Wells PS (October 2000). “Diagnostic value of the electrocardiogram in suspected pulmonary embolism”. Am. J. Cardiol. 86 (7): 807–9, A10. doi:10.1016/S0002-9149(00)01090-0. PMID 11018210.
  •  Amal Mattu; Deepi Goyal; Barrett, Jeffrey W.; Joshua Broder; DeAngelis, Michael; Peter Deblieux; Gus M. Garmel; Richard Harrigan; David Karras; Anita L’Italien; David Manthey (2007). Emergency medicine: avoiding the pitfalls and improving the outcomes. Malden, Mass: Blackwell Pub./BMJ Books. p. 10. ISBN 1-4051-4166-2.
  •  Shopp, Jacob D.; Stewart, Lauren K.; Emmett, Thomas W.; Kline, Jeffrey A. (2015-10-01). “Findings From 12-lead Electrocardiography That Predict Circulatory Shock From Pulmonary Embolism: Systematic Review and Meta-analysis”. Academic Emergency Medicine. 22 (10): 1127–1137. doi:10.1111/acem.12769. ISSN 1553-2712. PMC 5306533 Freely accessible. PMID 26394330. Archived from the original on 2015-11-28.
  •  Kucher N, Goldhaber SZ (2003). “Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism”. Circulation. 108 (18): 2191–4. doi:10.1161/01.CIR.0000100687.99687.CE. PMID 14597581.
  •  Lankeit M, Jiménez D, Kostrubiec M, Dellas C, Hasenfuss G, Pruszczyk P, Konstantinides S (December 2011). “Predictive value of the high-sensitivity troponin T assay and the simplified Pulmonary Embolism Severity Index in hemodynamically stable patients with acute pulmonary embolism: a prospective validation study”. Circulation. 124 (24): 2716–24. doi:10.1161/CIRCULATIONAHA.111.051177. PMID 22082681.
  •  McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT (1996). “Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism”. Am. J. Cardiol. 78 (4): 469–73. doi:10.1016/S0002-9149(96)00339-6. PMID 8752195.
  •  “UOTW #2 Answer – Ultrasound of the Week”. Ultrasound of the Week. Archived from the original on 12 January 2017. Retrieved 27 May 2017.
  •  National Institute for Health and Clinical Excellence. Clinical guideline 92: Venous thromboembolism: reducing the risk: Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. London, January 2010.
  •  Kearon, Clive; Akl, Elie A.; Ornelas, Joseph; Blaivas, Allen; Jimenez, David; Bounameaux, Henri; Huisman, Menno; King, Christopher S.; Morris, Timothy; Sood, Namita; Stevens, Scott M.; Vintch, Janine R.E.; Wells, Philip; Woller, Scott C.; Moores, COL Lisa (January 2016). “Antithrombotic Therapy for VTE Disease”. Chest. 149: 315–352. doi:10.1016/j.chest.2015.11.026. PMID 26867832.
  •  Vinson DR, Zehtabchi S, Yealy DM (November 2012). “Can selected patients with newly diagnosed pulmonary embolism be safely treated without hospitalization? A systematic review”. Annals of Emergency Medicine. 60 (5): 651–662.e4. doi:10.1016/j.annemergmed.2012.05.041. PMID 22944455.
  •  Yoo, Hugo H. B.; Queluz, Thais H. A. T.; El Dib, Regina (2016-01-12). “Anticoagulant treatment for subsegmental pulmonary embolism”. The Cochrane Database of Systematic Reviews (1): CD010222. doi:10.1002/14651858.CD010222.pub3. ISSN 1469-493X. PMID 26756331.
  •  Robertson, Lindsay; Jones, Lauren E. (9 Feb 2017). “Fixed dose subcutaneous low molecular weight heparins versus adjusted dose unfractionated heparin for the initial treatment of venous thromboembolism”. The Cochrane Database of Systematic Reviews. 2: CD001100. doi:10.1002/14651858.CD001100.pub4. ISSN 1469-493X. PMID 28182249.
  •  National Institute for Health and Clinical Excellence. Clinical guideline 144: Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing. London, 2012.
  •  Benson MD (October 2012). “Pulmonary embolism in pregnancy. Consensus and controversies”. Minerva ginecologica. 64 (5): 387–98. PMID 23018478.
  •  Palareti G, Cosmi B, Legnani C, Tosetto A, Brusi C, Iorio A, Pengo V, Ghirarduzzi A, Pattacini C, Testa S, Lensing AW, Tripodi A (2006). “D-dimer testing to determine the duration of anticoagulation therapy”. N. Engl. J. Med. 355 (17): 1780–9. doi:10.1056/NEJMoa054444. PMID 17065639.
  •  Yoo, Hugo H. B.; Queluz, Thais H. A. T.; El Dib, Regina (2016-01-12). “Anticoagulant treatment for subsegmental pulmonary embolism”. The Cochrane Database of Systematic Reviews (1): CD010222. doi:10.1002/14651858.CD010222.pub3. ISSN 1469-493X. PMID 26756331.
  •  Hirsh J, Guyatt G, Albers GW, Harrington R, Schünemann HJ (June 2008). “Executive summary: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)”. Chest. 133 (6 Suppl): 71S–109S. doi:10.1378/chest.08-0693. PMID 18574259.
  •  Lavonas, EJ; Drennan, IR; Gabrielli, A; Heffner, AC; Hoyte, CO; Orkin, AM; Sawyer, KN; Donnino, MW (3 November 2015). “Part 10: Special Circumstances of Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care”. Circulation. 132 (18 Suppl 2): S501–18. doi:10.1161/cir.0000000000000264. PMID 26472998.
  •  Kuo, William T.; Gould, Michael K.; Louie, John D.; Rosenberg, Jarrett K.; Sze, Daniel Y.; Hofmann, Lawrence V. (November 2009). “Catheter-directed Therapy for the Treatment of Massive Pulmonary Embolism: Systematic Review and Meta-analysis of Modern Techniques”. Journal of Vascular and Interventional Radiology. 20 (11): 1431–1440. doi:10.1016/j.jvir.2009.08.002. PMID 19875060.
  •  Engelberger, R. P.; Kucher, N. (3 February 2014). “Ultrasound-assisted thrombolysis for acute pulmonary embolism: a systematic review”. European Heart Journal. 35 (12): 758–764. doi:10.1093/eurheartj/ehu029. PMID 24497337.
  •  Hao, Q; Dong, BR; Yue, J; Wu, T; Liu, GJ (30 September 2015). “Thrombolytic therapy for pulmonary embolism”. The Cochrane Database of Systematic Reviews (9): CD004437. doi:10.1002/14651858.CD004437.pub4. PMID 26419832.
  •  Nakamura, S; Takano, H; Kubota, Y; Asai, K; Shimizu, W (Jul 2014). “Impact of the efficacy of thrombolytic therapy on the mortality of patients with acute submassive pulmonary embolism: a meta-analysis”. Journal of thrombosis and haemostasis : JTH. 12 (7): 1086–95. doi:10.1111/jth.12608. PMID 24829097.
  •  Chatterjee, Saurav; Chakraborty, Anasua; Weinberg, Ido; Kadakia, Mitul; Wilensky, Robert L.; Sardar, Partha; Kumbhani, Dharam J.; Mukherjee, Debabrata; Jaff, Michael R.; Giri, Jay (18 June 2014). “Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality, Major Bleeding, and Intracranial Hemorrhage”. JAMA. 311 (23): 2414. doi:10.1001/jama.2014.5990.
  •  Young, Tim; Tang, Hangwi; Hughes, Rodney (2010-02-17). Vena caval filters for the prevention of pulmonary embolism. John Wiley & Sons, Ltd. doi:10.1002/14651858.cd006212.pub4. ISSN 1465-1858. Archived from the original on 2015-12-03.
  •  Augustinos P, Ouriel K (2004). “Invasive approaches to treatment of venous thromboembolism”. Circulation. 110 (9 Suppl 1): I27–34. doi:10.1161/01.CIR.0000140900.64198.f4. PMID 15339878.
  •  Wood, Kenneth E. (2002). “An approach to Venous Thomboembolism/Pulmonay Embolism in the Critically Ill”. In Murray, Michael J.; Coursin, Douglas B.; Pearl, Ronald G.; et al. Critical Care Medicine: Perioperative Management: Published Under the Auspices of the American Society of Critical Care Anesthesiologists (ASCCA). Lippincott Williams & Wilkins. p. 536. ISBN 978-0-7817-2968-0.
  •  Walker RH, Goodwin J, Jackson JA (17 October 1970). “Resolution of Pulmonary Embolism”. British Medical Journal. 4 (5728): 135–9. doi:10.1136/bmj.4.5728.135. PMC 1819885 Freely accessible. PMID 5475816.
  •  Le Gal G, Righini M, Parent F, van Strijen M, Couturaud F (2006). “Diagnosis and management of subsegmental pulmonary embolism”. J Thromb Haemost. 4 (4): 724–31. doi:10.1111/j.1538-7836.2006.01819.x. PMID 16634736.
  •  Perrier A, Bounameaux H (2006). “Accuracy or outcome in suspected pulmonary embolism”. N Engl J Med. 354 (22): 2383–5. doi:10.1056/NEJMe068076. PMID 16738276. Archived from the original on 2007-02-11.
  •  White RH (October 2008). “Risk of fatal pulmonary embolism was 0.49 per 100 person-years after discontinuing anticoagulant therapy for venous thromboembolism”. Evid Based Med. 13 (5): 154. doi:10.1136/ebm.13.5.154. PMID 18836122.
  •  Barritt DW, Jordan SC (1960). “Anticoagulant drugs in the treatment of pulmonary embolism: a controlled trial”. Lancet. 1 (7138): 1309–12. doi:10.1016/S0140-6736(60)92299-6. PMID 13797091.
  •  Jiménez D, Yusen RD, Otero R, Uresandi F, Nauffal D, Laserna E, Conget F, Oribe M, Cabezudo MA, Díaz G (2007). “Prognostic models for selecting patients with acute pulmonary embolism for initial outpatient therapy”. Chest. 132 (1): 24–30. doi:10.1378/chest.06-2921. PMID 17625081.
  •  Zhou, Xiao-Yu; Ben, Su-Qin; Chen, Hong-Lin; Ni, Song-Shi (2012). “The prognostic value of pulmonary embolism severity index in acute pulmonary embolism: a meta-analysis”. Respiratory Research. 13 (1): 111. doi:10.1186/1465-9921-13-111. ISSN 1465-9921.
By |2018-08-25T10:47:02+00:00August 6th, 2018|Disease/pathological condition|0 Comments

About the Author:

B. Pharm (K.L.E. society's S.V.V. Patil College of Pharmacy, Bengaluru) M. Pharm (Maharishi Arvind Institute of Pharmacy, Jaipur)

Leave A Comment

WE NEED YOUR HELP IN CREATING AWARENESS ABOUT DISEASES AND MEDICINES

In today's fast paced life, we often come across minor health issues that we often neglect due to lack of time for paying a visit to a doctor, which usually takes away 2-3 hours of a person's time and are expensive too. Further more, such minor conditions may grow big at any time if neglected. Our aim in setting up this platform is that any person can search for any health condition or medicines and can get all the needed information within hardly 10-15 minutes, which saves a lot of time and money. After going through every information, if the person has any questions, he/she can go to our forums section and raise a topic. This will help him/her decide better whether he/she needs to pay an immediate visit to a doctor or can it wait for a day or two? Help us in bringing awareness about diseases and medicines by spreading the word to at least 5 of your friends and relatives.
Select your currency