Warning:
• Diagnosis evoked by context and promoting the clinic.
• Any suspected pulmonary embolism (PE) requires a transfer to hospital for confirmation and initiation of anticoagulation.
• Do not ignore the imperfect forms, particularly without obvious phlebitis
Clinic:
The context is thrombophlebitis (see), but not always!
functional signs: pain, sudden or increasing dyspnea, cough, hemoptysis.
Physical signs: fever, tachypnea, tachycardia, phlebitis associated (but sometimes absent clinically), cyanosis, pulmonary burst of B2, éjectionnel pulmonary systolic murmur, or tricuspid regurgitation.
misleading forms: OAP, bronchospasm, angina, syncope, worsening of dyspnea usual.
severe (acute right heart failure): hepatalgia, IVD signs of respiratory distress with shock, intense cyanosis.
Additional tests:
– ECG (interest of a previous ECG) +++ sinus tachycardia or atrial rhythm disorders, signs of right atrial enlargement, right axis deviation, appearance S1Q3, incomplete right ++ block, ischemia subepicardial anteroseptal; However, inconsistent ++ changes in crude forms.
– Echocardiography Doppler: indirect signs (dilation of the right cavities, paradoxical septum, and tricuspid insufficiency signs PAH), sometimes direct signs of a thrombus in the right cavities (against-indicating pulmonary arteriography) or the trunk of the AP, assessment of cardiac output. The review oesophageally (if any) can sometimes visualize the proximal thrombus.
– Chest X-ray in bed ++ climbing a dome, atelectasis in bands, filling pleural cul-de-sac, located hypovascularisation, amputation of a pulmonary artery, cardiomegaly right; however, may be normal ++.
– Blood Gas: non-specific hypoxemia hypocapnia, witnesses of gravity.
– Determination of D-dimer: sensitive (excellent negative predictive value) but not specific.
– Lung scintigraphy ventilation / perfusion: normal, it eliminates the diagnosis +++; abnormal, there are many false positives.
– MR angiography and pulmonary angiography scanner: not traumatic, very efficient for diagnostics.
Moreover, looking for signs of DVT +++ +++ clinical and laboratory.
To behave:
– Evoking the outset diagnosis.
– Assess the severity of the clinical picture.
– Possible Oxygen.
– Refer the patient in hospital medical transport (ambulance).
Order No. 1: pulmonary embolism small or medium importance
– Strict rest in bed
– Oxygen therapy and monitoring SaO2 continuously.
– Heparin Syringe: bolus of 100 IU / kg followed IVD 500 IU / kg / day to adapt aPTT (2 to 3 times the control)
or simpler: INNOHEP [tinzaparin sodium] 175 IU / kg / day in a single subcutaneous injection daily (monitoring of anti-Xa activity is indicated in cases of renal failure in the subject aged: it must be less than 1.5 anti-Xa IU / ml)
– Early relay by PREVISCAN [fluindione] 1 tablet daily, then adjust according to (INR between 2 and 3):
– Down ++ venous contention,
– Authorized up from the correct hypocoagulability obtained.
– Duration of anticoagulation: 6 months, or for life in case of recurrence risk factor (antiphospholipid syndrome, coagulation factor deficiencies …).
Ordinance No. 2: severe pulmonary embolism with shock
– In ICU
– In the absence of indication-cons, thrombolysis with Actilyse [alteplase] 100 mg IV over 2 hours followed by Heparin Syringe 400-600 IU / kg / day
– The power inotropespositives drugs
– Whether against-indications to thrombolysis, emergency surgery.
Indication of the partial interruption of the inferior vena cava:
To discuss ; some are temporary and removable devices.
– Extension of thrombophlebitis, recurrent PE despite adequate treatment.
– Formal contraindication to anticoagulants.
– Chronic Pulmonary Heart postembolique and recent venous thrombosis.
– Clot floating in the inferior vena cava.