Kenapa pt pulmonary embolism dapat tachycardia?

Pernah terfikir tak.

#tweetorial #foamed

Tachycardia ialah sign yg ketiga paling common dalam kes PE.

Ini adalah dapatan dari kajian, Prospective Investigation of Pulm Embolism Diagnosis (PIOPED).

Dyspnea dan tachypnea, okay faham sebab lung compromised. Tapi kenapa tachycardia?

First remember your physiology

Cardiac output = SV x HR

Stroke volume = End diast vol x End sys vol

Apa jadi dalam PE?

Blood clot terjerat dalam pulm vasculature, like u who are trapped in the memories of your ex.

And like u yg takmau dengar nasihat rakan sebaya, blood clot ni menghalang darah dari right side of the heart masuk ke lungs.

Hence increase in Pulm v. resistance

pulm vasc. Resistance, right ventricle kena pump harder, right ventricle dilated, and bowing of interventricular septum.

Ingat tak dulu pernah bincang, pulm arteries ni kalau hypoxic, dia akan vasoconstric. Ni pun akan pulm vasc resistance.

So apa jadi? preload pun sebab flow into left ventricle.

Jadi kalau heart nak maintain normal cardic output, dengan stroke vol yg dah ni. Heart rate kena

(CO = SV x HR)

Sebab tu la tachy!

Okay now, u suspect pt ada PE. macam mana nak diagnose PE?

D-dimer ada role ke tak?

Definitive diagnosis untuk PE ialah ctpa. Tapi takkan la semua pt ada sob, tachycardia, u nak hantar pergi ctpa. Siapa pernah jdi houseman mesti tahu perasaan nak pergi req imaging tu mcm nak jwab soalan munkar naqir.

So kita ada Well’s score

Well’s score alone ada sensitivity and specificity of 72 and 62% (Bass AR et al) tapi kalau u guna sekali d-dimer, sensitivity upto 99%

So macam mana nak guna?

D-dimer ni apa sebenarnya? Dia ialah fibrin degradation product. So kalau ada venous thromboembolism, dic, and pregnancy pun akan .

Back to well’s score for pe.

If score >4, proceed ctpa

Score < or equal 4, buat d-dimer

Kalau d-dimer +, consider proceed ctpa

If negative, u can safely say pt takda PE.

If patient buat ctpa tapi negative? Kena double confirm, buat bilateral compression usg.

(Malaysia CPG on VTE)

Okay pt tu confirm ada PE. Apa nak buat? Start LMWH. Sebenarnya kalau pe likely, dah kena start within 24h nak sebelum pergi ctpa lagi.

*psst lmwh tu apa bang?

Heparin ada 2 jenis:

1. Lmwh tu adik beradik dia Enoxaparin, Tinzaparin, Dalteparin.
-inactivate factor Xa

2. Kalau heparin biasa yg kena monitor aptt tu, unfractionated heparin.
-inhibit thrombin, IXa dan Xa.
-Rapid onset of action. Sebab tu guna ni utk bridging.

So confirm diagnosis, start Lmwh together with Warfarin*

*warfarin ni apa? Vitamin K antagonist

Continue treatment ni sampai INR > 2 atau for 5 days, whichever is longer. Contoh kalau inr dah lebih dua, tapi belum cukup 5 hari, sambung cukup 5.

Lepas tu cont warfarin ja.

So berapa lama nak continue warfarin pulak? Ni tricky question. Kena tengom banyak factor, risk of recurren, risk of bleeding etc. usually 3 months, kalau cancer maybe 6/12.

Clinical practice guideline cakap apa?

Okay so macam tu lah lebih kurang pasal PE.

Tapi ingat ni untuk hemodynamically stable pe. Kan patient ni boleh dtg dgn shock, hypotensive (sebab reduced stroke vol etc wink wink ingat lagi?). Kalau unstable, lain sikit. Resus fluid, maintain bp.

Pernah dengar pasal S1Q3T3 tak? Sebenarnya finding ni rare, tapi ni contoh real life case; https://twitter.com/shariqshamimmd/status/1327397108345835521

Okay thank you for coming to my tedtalk.

*last soalan untuk u, so kalau pt pregnant, macam mana nak diagnose PE?