I know this will be very exciting for many of you. For work, I was asked to read an article and give a summary of it. This is a review article on acute pulmonary embolisms and how they are treated and dealt with, mainly in the hospital setting.
For your pleasure, if you want to go and find the article:
Agnelli, Giancarlo and Cecilia Becattini. (2010). Acute Pulmonary Embolism. The New England Journal of Medicine, 363(3), 266-74.
A pulmonary embolism is a serious problem that should be considered in several classes of patients. Those with new or worsening difficulty breathing, chest pain or sustained hypotension without an obvious alternative cause should be assumed until proven otherwise.
Each patient should undergo a clinical probability assessment to determine the likelihood of the patient experiencing a PE through either clinical judgment or clinical decision rules (Wells and revised Geneva scores). During the assessment, the patient is determined to be hemodynamically stable or unstable. The stable category is split into two further categories: low/intermediate clinical probability and high clinical probability. Those with the high clinical probability will proceed to the CT scan to confirm or rule out the presence of a pulmonary embolism. The low/intermediate clinical probability group will receive D-dimer testing. The results of that test will determine the next step for the patient. Caution should be used for elderly patients, pregnant women and patients with cancer as the specificity of an increased D-dimer level is reduced in these populations. A normal D-dimer result rules out a pulmonary embolism. If it is elevated, the patient is sent to the CT scanner to determine the presence or absence of a PE.
The hemodynamically unstable patients are also divided into two categories: not critically ill and critically ill/high clinical probability. Those who are not critically ill will, if available, be sent to a CT scanner to confirm or rule out a pulmonary embolism. If not CT scanner is available, the patient will receive a transthoracic or transesophageal echocardiogram. The specific results that the attending physician will look for are the presence or absence of right ventricular dysfunction. If right ventricular dysfunction is present, a diagnosis of pulmonary embolism is confirmed. If not right ventricular dysfunction is present, a search for an alternative diagnosis must begin. For the critically ill/high clinical probability category, they will proceed straight to the transthoracic or transesophageal echocardiogram.
Management of patients in the hospital setting with an acute pulmonary embolism should be based on a system of stratification based on clinical features. Patients need to be monitored for hemodynamic stability. Hemodynamically unstable is defined as shock or sustained hypotension. This will include a systolic blood pressure below 90 mm Hg or a blood pressure drop of greater than 40 mm Hg for greater than 15 minutes. These patients need to proceed to thrombolysis, surgery or catheter embolectomy. Hemodynamically stable patients will be evaluated for other clinical and cardiac features such as assessing for right ventricular dysfunction (through echocardiogram or a CT scan) and right ventricular injury (through Troponin/cardiac enzyme testing). This will yield one of three categories for the patient. The first category of patients, no dysfunction or injury, will continue their anticoagulation treatment and consider admission and early discharge or home treatment. The second category, those with dysfunction only, will continue their anticoagulation treatment and receive admission to a medical ward. The final group, those with dysfunction and injury, will be considered for ICU admission or thrombolysis in patients at low risk for bleeding complications.
Treatment of these patients is not a quick-fix but rather a long process. Initial pharmacological treatment is done with anticoagulants and vitamin K antagonists while being supplemented by surgery and percutaneous mechanical embolectomy as appropriate. This treatment will extend for approximately five days (pharmacologically). The long-term treatments are typically vitamin K antagonists. These are used for at least three months. For patients with a high risk for recurrence, an extended treatment of vitamin K antagonists is prescribed. The risk for patients to have a second pulmonary embolism, while on anticoagulant treatment, is less than 1% per year. However, the risk is between 2 and 10% when not on this treatment. Some of the stronger risk factors for recurrence include sex (specifically male), advanced age (read: old) and an idiopathic (read: no known cause) pulmonary embolism. The risk among cancer patients is especially high.
No comments:
Post a Comment