although the terms do not help with decision making around duration of treatment 2 terms are often used:
Provoked PE - associated with a recent (≤3 months) and transient major risk factor, such as significant immobility, surgery, trauma, pregnancy or puerperium, or use of hormonal therapy (combined contraceptive pill or hormone replacement therapy)
Unprovoked PE - occurs in the absence of a recent (≤3 months) major clinical risk factor in a person who is not using hormonal therapy.
Clinical
may be asymptomatic
SOB, cough +/- haemotypsis
pleuritic chest pain
associated leg pain/swelling, signs of DVT
massive PE - central cyanosis, altered/LOC, collapse or shock
tachypnoea, tachycardia, hypotension
elevated JVP, parasternal heave, loud P2
Fever is common in PE and can occur in ≥25% patients
clinical categorisation to direct Mx:
massive (high risk)- shock, persistent brady or asystole
sub-massive (intermediate risk) - evidence of RV dysfunction but no signs of shock
low risk - no evidence of RV dysfunction or shock
Investigations
bloods: FBC, U&E's, clotting, d-Dimer
ECG - often normal
sinus tachycardia
signs of R heart strain -SI, QIII, TIII (probably <10%), non-specific ST changes or TWI in anterior leads, right axis deviation, S wave (I and aVL) > 1.5mm, Q in III and aVF, P pulmonale & RBBB
ABG - hypoxia. Repeat after exercising may enhance diagnostic workup. Resp alkalosis. Metabolic acidosis if shock
CXR - only to rule out other pathology
CTPA - may not pick up smaller emboli
If no obvious cause, risk factors Ix should follow:
Antithrombin III deficiency
Protein C or protein S deficiency
Lupus anticoagulant
Homocystinuria
Occult neoplasm
Connective tissue disorders
Management
Low molecular weight heparin (LMWH)
Fondaparinux.
Unfractionated heparin.
Oral anticoagulants: Warfarin, apixaban, or rivaroxaban.
LMWH followed by an oral anticoagulant (dabigatran or edoxaban)
Thrombolysis - only for massive. Debate continues about their place in sub-massive
plasminogen activators - fibrin specific rt-PA or non selective agents - streptokinase, urokinase