Pulmonary emboli

Non-cardiac Anemia, anxiety disorders, carbon monoxide poisoning, cocaine use, esophageal reflux, peptic ulcer, pleuritis, pneumonia, pneumothorax, pulmonary embolus, pulmonary hypertension, thyrotoxicosis... 

Cardiac arrhythmia Hypertonic crisis Pulmonary embolus Capillary leak syndrome... 

Heparin and warfarin are widely used in the treatment of thrombotic and thromboembolic conditions, such as deep vein thrombosis and pulmonary embolus. Heparin is administered first, because of its prompt onset of action, whereas warfarin takes several days to reach full effect. Their effects are closely monitored by use of appropriate tests of coagulation (see below) because of the risk of producing hemorrhage. 

Inappropriate pulmonary ventilation In acutely ill patient" eg. Myocardial infarct Pulmonary embolus Shock... 

Asthma, Early Pulmonary Embolus Shock, Late... 

Lenalidomide was approved recently for the indication of myelodysplastic syndrome where the 5q deletion is present. Since lenalidomide is an analog of thalidomide, all the same precautions must be taken to prevent phocomelia. The time to maximum lenalidomide concentrations occurs 0.5 to 4 hours after the dose. The terminal half-life ranges from 3 to 9 hours. Approximately 65% of lenalidomide is eliminated unchanged in the urine, with clearance exceeding the glomerular filtration rate. To date, no pharmacokinetic studies have been done in patients with renal dysfunction. Lenalidomide is used in the treatment of myelodysplastic syndrome and multiple myeloma. Other side effects are neutropenia, thrombocytopenia, deep vein thrombosis, and pulmonary embolus. 

The predominant mechanism of AF and atrial flutter is reentry, which is usually associated with organic heart disease that causes atrial distention (e.g., ischemia or infarction, hypertensive heart disease, valvular disorders). Additional associated disorders include acute pulmonary embolus and chronic lung disease, resulting in pulmonary hypertension and cor pulmonale and states of high adrenergic tone such as thyrotoxicosis, alcohol withdrawal, sepsis, or excessive physical exertion. 

Patients often present with classic signs and symptoms of acute pulmonary embolus pleuritic chest pain, fever, hemoptysis, a friction rub, and a wedge-shaped infiltrate on chest radiographs. 

It is remarkable that most of the data collected from the available SERMs are unanimous in reproducing an estrogen agonistic profile in venous thrombogenesis. The vast clinical experience acquired with tamoxifen confirms an augmented risk for both deep venous thrombosis and pulmonary embolism. This increase, however, did not presuppose increased mortality in the overview of randomized trials of adjuvant tamoxifen for early breast cancer, where the one extra death per 5000 woman-years of tamoxifen attributed to pulmonary embolus was not statistically significant (Early Breast Cancer Trialists Collaborative Group 1998). 

In a fatal human exposure, a worker engaged in emptying metal gas cylinders of methyl mercaptan was found comatose at the work site he developed expiratory wheezes, elevated blood pressure, tachycardia, and marked rigidity of extremities. Methemoglobinemia and severe hemolytic anemia developed with hematuria and proteinuria but were brief in duration deep coma persisted until death due to pulmonary embolus 28 days after exposure. It was determined that the individual was deficient in erythrocyte glucose-6-phosphate dehydrogenase, which was the likely cause of the hemolysis and formation of methemoglobin. 

PDGF platelet-drived growth factor PE pulmonary embolus, physical examination, pleural effusion PEA pulseless electrical activity PFT pulmonary function test pg picogram... 

Lenalidomide, a derivative of thalidomide, was introduced in 2004. Patients with multiple myeloma stage II/III, who have undergone at least one previous treatment can be treated with bortezomib or with lenalidomide in combination with dexamethasone. There is good oral absorptin with peak plasma levels at 0.5-4 hours. Lenalidomide is maily eliminated by the kidneys with a half-life of circa 3-9 hours. Teratogenicity cannot be excluded. Side effects include thrombosis, pulmonary embolus, and hepato-toxicity, as well as bone marrow toxicity resulting in neutropenia and thrombocytopenia. 

Vorinostat (Zolinza) is a histone deacetylase inhibitor that is approved for the treatment of cutaneous T-cell lymphoma in patients with progressive, persistent, or recurrent disease on or after two systemic therapies. The recommended dosing is 400 mg orally once daily. Adverse effects include pulmonary embolus, deep vein thrombosis, thrombocytopenia, anemia, and gastrointestinal disturbances. 

Scolding NJ, Gibby OM. Fatal pulmonary embolus in a patient treated with Marvelon. J R Coll Gen Pract 1988 38(317) 568. 

Troponin levels are an important addition to stratify risk in the ACS patient with history and electrocardiographic changes. However, abnormal troponins are found in other conditions as well, notably pulmonary embolus and sepsis, when ACS patients are excluded. These authors suggest that elevated troponin levels are not specific for ACS (II). This requires clinical evaluation (Table 2). 

Medications such as P-blockers, calcium channel blockers, digoxin, and amiodarone can be used to control cardiac conduction abnormalities (arrhythmias), and a pacemaker may be inserted to combat heart failure. The general supportive care measures used in acute stroke syndromes also should be followed. Death in patients with MELAS is usually the result of cardiac failure, pulmonary embolus, or renal failure. 

Matsuo O, Rijken DC, Collen D (1981) Thrombolysis by human tissue plasminogen activator and urokinase in rabbits with experimental pulmonary embolus. Nature 291 590-591 Nicolini FA, Lee P, Rios G et al. (1994) Combination of platelet fibrinogen receptor antagonist and direct thrombin inhibitor at low doses markedly improves thrombolysis. Circulation 89 1802-1809... 

Embolism associated with long flights is generally due to thrombus formation in deep leg veins (deep-vein thrombosis, or DVT). The thrombus may move to the pulmonary circulation, where effects on lung function depend on the extent of the blockage produced. A massive embolus may occlude the main pulmonary artery, resulting in hypotension, shock and possibly death multiple small emboli cause little problem and are lysed by the fibrinolytic system. Sometimes surgical removal of the embolus is necessary, but in Pats/s case clot lysis was successful and she made an uneventful recovery. 

Q7 What happens to the area of lung whose circulation has been cut off by an embolus in a pulmonary blood vessel ... 

Q6 A thrombus is a blood clot which is fixed to the blood vessel wall. When it detaches and is carried in the blood, it is known as an embolus. Both thrombi and emboli can block blood vessels and deprive tissues of oxygen. In arteries blood clots usually form because the inner surface has been altered by deposition of atheroma. In contrast venous thrombosis results from slow or stagnant blood flow in veins, or defects in mechanisms which normally oppose inappropriate coagulation. Three major risk factors for pulmonary embolism are (i) venous stasis, (ii) hypercoagulability ofblood and (iii) injury to vascular endothelium following trauma or plaque rupture. 

Q7 If the embolus is quite large and obstructs a significant area of the pulmonary circulation, the affected area of lung will be underperfused or non-perfused. The area may continue to be ventilated for some time, causing a ventilation-perfusion mismatch, which leads to poor gas exchange and abnormal blood gas tensions. The lung volume in the affected area decreases, and this decrease in size can sometimes be seen on a chest X-ray. After some hours, surfactant production declines in the non-perfused area of lung and the alveoli collapse. 

Ihde-Scholl T, Rolli ML, Jefferson JW. Clozapine and pulmonary embolus. Am J Psychiatry 2001 158(3) 499-500. 

The short term prognosis after major stroke depends on stroke subtype (Table 16.1), the occurrence of stroke-associated complications, stroke extension or recurrence. Whilst stroke subtype is fixed, optimal acute stroke treatment can impact on stroke morbidity and mortaUty through minimizing the UkeUhood of neurological deterioration and the occurrence of compUcations such as pulmonary embolus and pneumonia (Ch. 20) as well as through the administration of specific therapies (Ch. 21). 

Emergencies such as major haemorrhage, pulmonary embolus, severe choking, fracture of large bone give morphine 10 mg plus hyoscine 0.4 mg i.m. this combination provides acute relief and some desirable short-term retrograde amnesia which may extend to the whole unpleasant episode. 

Stocking to increase flow in deep veins, should exercise the leg and should be encouraged to mobilise as soon as the discomfort has settled. The risk of recurrence reduces with passage of time after the initial event. In cases of DVT imcomplicated by pulmonary embolus, 3 months of anticoagulant therapy appears adequate. Where there is evidence of pulmonary embolus it is common practice to continue therapy for 6 to 12 months. 

In 910 patients toxicity was life-threatening in 0.55% (41). A combination of cisplatin, fluorouracil, and eto-poside given for advanced non-small cell cancer of the lung caused only the expected amount of hematological toxicity, but was associated with a higher than expected incidence of cardiac, pulmonary, and cerebrovascular toxicity, including two myocardial infarctions, two cases of congestive heart failure, one pulmonary embolus, and one cerebrovascular accident in a study of 35 patients (42). 

Of 50 patients with multiple myeloma, 14 developed a deep venous thrombosis after taking thalidomide 400 mg/day, compared with two of 50 patients who did not take it (24) All the episodes occurred during the first 3 cycles of therapy. One patient taking thalidomide had a pulmonary embolus. Most of the patients continued to take thalidomide with the addition of low molecular weight heparin followed by warfarin and there was no progression of deep venous thrombosis. 

In a study of the combination of thahdomide 100 mg/day with darbepoetin aha 2.25 mg/kg/day in patients with myelodysplastic syndromes, there was an unexpectedly high incidence of thromboembohc events (194). Of the first seven patients emolled, two developed deep vein thromboses and one died of a massive pulmonary embolus. The authors concluded that thalidomide may increase the thromboembolic risk associated with erythropoietic proteins in patients with myelodysplastic syndromes. 

Ten days later she developed a persistent fever. A chest X-ray and a CT scan showed bilateral pleural effusions and interstitial infiltrates, but no pulmonary embolus. Tretinoin was withdrawn and she was given intravenous dexamethasone 10 mg every 12 hours. Her fever disappeared within 24 hours and her respiratory distress gradually improved during the next 24-48 hours. A chest X-ray 7 days later showed total resolution. 

HOCM, Hypertrophic obstructive cardiomyopathy LVH, left ventricular hypertrophy 5 FU, 5 fluorouracil PE, pulmonary embolus PCI, percutaneous coronary mteivention TBSA, total surface body area ... 

Other causes of acute cough with or without dyspnea Other causes of acute pulmonary edema Pulmonary embolus... 

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