* Difficult diagnosis because signs are not very sensitive and not very specific.
* acute dyspnea of polypnea type (70%), cough (40%).
* chest pain (60%) with or without hemoptysis (10%), tachycardia (30%), sometimes inaugural syncope (10%).
* fever between 37.5 ° and 38.5 ° C.
* the signs are frustrated in the elderly:
– think about dyspnea or malaise rather than chest pain.
– think of it as worsening of dyspnea in a patient with heart disease or COPD.
* clinical signs of severity:
– respiratory rate> 30 / min, cyanosis.
– lipothymia, agitation, torpor.
– signs of right ventricular failure:
– jugular turgor, hepato-jugular reflux, painful hepatomegaly.
Collapse <90 mmHg, tachycardia> 110 / min.
* look for signs of thrombophlebitis (20%).
DIFFERENTIAL DIAGNOSIS:
* other chest pain:
– IDM, aortic dissection, acute pericarditis, tamponade, acute pneumonitis, pneumothorax, digestive emergencies.
ETIOLOGY:
* Deep thrombophlebitis of the lower limbs.
* taking estrogen-progestins.
* post-operative or post-partum period.
* prolonged immobilization , plastered restraint.
* chronic respiratory failure, neoplasia.
* abnormalities of hemostasis.
DIAGNOSTIC TESTS:
* scope, SpO².
* ECG :
– to compare if possible with an earlier ECG.
– normal in minor to moderate forms.
– modifications in the more severe forms: right branch block, QRS deviation.
– if severe form: aspect S1Q3, disorders of the repolarization in precordial straight.
* chest x-ray :
– normal (25%).
– dome ascension, pulmonary arterial distention, minimal pleural effusion, flat or discoid atelectasis, focal hypovascularization, infarct condensation.
– Eliminate some differential diagnoses: pneumonitis, pneumothorax.
* if D-dimers made by the Elisa technique <500 μg / l: no pulmonary embolism (97%).
* standard biological assessment, hemostasis.
* blood gas: hypoxemia-hypocapnia inconstant, SpO2 <60% if severe form.
* then as soon as possible:
– Doppler ultrasound in emergency but not always available.
– echocardiography: useful for eliminating other diagnoses.
– scintigraphy: if normal, one can conclude that it is not a pulmonary embolism.
– spiral CT angiography that signs the diagnosis.
TREATMENT:
* venous route: G5%, mask oxygen therapy: 6 to 8 l / min.
Venous restraint if associated phlebitis.
* hospitalization.
* heparinotherapy :
– Heparin loading dose: 100 IU / kg IV direct.
– then Heparin continuous: 400-500 IU / kg / day.
Or Innohep: 175 IU anti-Xa / kg in one subcutaneous injection per day (0.1 ml / 10 kg) -0.1 ml.
* if collapse: Plasmion, 500 ml and Dobutrex, 5 μg / kg / min.
* if respiratory distress, convulsions, circulatory arrest:
– Intubation and assisted ventilation after possible anesthesia (Hypnovel: 0.05 mg / kg IV + Fentanyl: 1 μg / kg IV).
* hospitalization, in intensive care if signs of gravity.
* fibrinolysis for severe or poorly tolerated pulmonary embolism:
– 15000 IU / kg bolus (10 min) for urokinase and 0.6 mg / kg bolus for r-tPA, combined with heparin, alteplase: 100 mg / 2 hours.