Pulmonary embolism acute, treatment

Coexisting diseases precipitate DKA and DKA precipitates coexisting disease. Most often patients with DKA suffer from infectious disease and signs of infection should be vigorously sought for and treatment should be instituted on wide indications. Other prominent co-morbidities include cardiovascular events (myocardial infarction, stroke, thrombophlebitis, pulmonary embolism), acute gastrointestinal disorders and a variety of intoxications. 

Thrombolytic Enzymes. Although atherosclerosis and the accompanying vascular wall defects are ultimately responsible for such diseases as acute pulmonary embolism, arterial occlusion, and myocardial infarction, the lack of blood flow caused by a fibrin clot directly results in tissue injury and in the clinical symptoms of these devastating diseases (54). Thrombolytic enzyme therapy removes the fibrin clot by dissolution, and has shown promise in the treatment of a number of thrombo-occlusive diseases (60). 

Indications for treatment with streptokinase include acute occlusion of arteries, deep vein thrombosis, and pulmonary embolism. Streptokinase therapy in coronary thrombosis, which is the usual cause of myocardial infarction (54,71,72), has proved to be valuable. In this frequently fatal condition, the enzyme is adrninistered intravenously at a dose of 1.5 million units over 60 min, or given by intracoronary infusion at a 20,000- to 50,000-unit bolus dose followed by 2000 to 4000 units/min for 60 min therapy must be instituted as soon as practicable after the diagnosis of heart attack is made. For deep vein thrombosis, pulmonary embolism, or arterial occlusion, streptokinase is infused at a loading dose of 250,000 units given over 30 min, followed by a maintenance dose of 100,000 units over a 60-min period. 

Streptokinase is administered by intravenous or intra-arterial infusion in the treatment of thrombo-embolic disorders, e g. pulmonary embolism, deep-vein thrombosis and arterial occlusiorrs. It is also used in acute myocardial irtfarclioa... 

In stroke patients presenting to the ED, the first goal of treatment is immediate cardiac and respiratory stabilization. The systemic blood pressure is most often elevated in the setting of an acute stroke as the result of a catecholamine surge, and if the patient is hypotensive, the clinician should consider a concomitant cardiac process, such as myocardial infarction (MI), congestive heart failure (CHF), or pulmonary embolism (PE). 

Alteplase was the first commercially available recombinant tissue-type plasminogen activator (rt-PA) (25), It has a plasma half-life of less than five minutes and is metabolized by the liver, This agent was initially hailed as fibrin-specific unlike its precursors (urokinase and streptokinase). It was thought that this would result in a better safety profile, but this has not been born out in either the coronary or the peripheral experience, where actually there may be a higher bleeding risk as infusion time increases. Alteplase is currently indicated for use in the treatment of myocardial infarction, acute ischemic stroke, and pulmonary embolism. 

Goldhaber SZ, Kessler CM, Heit J, et al. Randomized controlled trial of recombinant tissue plasminogen activator versus urokinase in the treatment of acute pulmonary embolism. Lancet 1988 2 293-298. 

Therapeutic uses Originally used for the treatment of deep-vein thrombosis and serious pulmonary embolism, thrombolytic drugs are now being used with increasing frequency to treat acute myocardial infarction and peripheral arterial thrombosis and emboli, and for unclotting catheters and shunts. 

Therapeutic uses Currently alteplase is approved for the treatment of myocardial infarction, massive pulmonary embolism, and acute ischemic stroke. Alteplase seems to be superior to streptokinase and urokinase in dissolving older clots, and may ultimately be approved for other applications. Alteplase administered within 3 hours of the onset of ischemic stroke significantly improves clinical outcome, that is, the patients ability to perform activites of daily living. 

Four major and five minor clinical patterns of acute phencyclidine intoxication have been described in 1000 patients (7). Major patterns were acute brain syndrome (24.8%), toxic psychosis (16.6%), catatonic syndrome (11.7%), and coma (10.6%). Minor patterns included lethargy or stupor (3.8%) and combinations of bizarre behavior, violence, agitation, and euphoria in patients who were alert and oriented (32.5%). Patients with major patterns of toxicity usually required hospitalization and had most of the complications. Patients with minor patterns generally had mild intoxication and did not require hospitalization, except for treatment of injuries or autonomic effects of phencyclidine. There were various types of injuries in 16%, and aspiration pneumonia in 1.0%. There were 22 cases of rhabdomyolysis (2.2%), and three patients required dialysis for renal insufficiency. One patient who had been comatose died suddenly with a pulmonary embolism. 

The convenience (and cost-effectiveness) of LMW heparin therapy has resulted in widespread changes in practice. Patients with acute venous thromboembolism can be treated safely and effectively with LMW heparin as outpatients. Large-scale studies have demonstrated that outpatient treatment of acute deep vein thrombosis (DVT) with unmonitored body-weight adjusted LMW heparin is as safe and effective as inpatient treatment with adjusted dose intravenous standard heparin. Further trials have confirmed the safety and efficacy of LMW heparin therapy in acute pulmonary embolism and that 80% of imselected patients with acute thromboembolism can be safely treated as outpatients. ... 

Tissue plasminogen activator 530 amino acids — glycosylated Activase (Genentech) E. coli Yeast Animal cells Treatment of acute mycocardial infarct and pulmonary embolism... 

Clinical uses include treatment of acute myocardial infarction, pulmonary embolism and peripheral thromboembolism and in the restoration of circulation through arterial grafts and intravenous catheters. 

Fondaparinux is a selective inhibitor factor Xa possessing a selective inhibition of antithrombin III (ATIII), which potentiates the innate neutralization of factor Xa by ATIII. Nentralization of factor Xa interrupts the blood coagulation cascade and inhibits thrombin formation and thrombus development. It is indicated for prophylaxis of deep vein thrombosis (DVT) that may lead to pulmonary embolism in patients undergoing hip fracture surgery including extended prophylaxis, hip replacement surgery, or knee replacement surgery. When administered in conjunction with warfarin, fondaparinux is indicated for treatment of acute DVT and acute pulmonary embolism. 

Heparin is an anticoagulant that inhibits reactions that lead to clotting. It is indicated in prophylaxis and treatment of venous thrombosis and its extensions, pulmonary embolism (PE), peripheral arterial embolism, and atrial fibrillation with embolization diagnosis and treatment of acute and chronic consumption coagulopathies (DIC) and prevention of postoperative deep venous thrombosis. 

Streptokinase (1,500,000 lU within 60 minutes by fV infusion) is indicated in lysis of coronary artery thrombosis after acute myocardial infarction streptokinase (250,000 lU by IV infusion pump into each occluded limb of the cannula over 25 to 35 minutes) is indicated in arteriovenous cannula occlusion and streptokinase (250,000 lU IV infusion over 30 minutes) is indicated in the treatment of venous thrombosis, pulmonary embolism, and arterial thrombosis and embolism. 

Tinzaparin sodium is a low-molecular-weight heparin that inhibits reactions leading to the clotting of blood, including the formation of fibrin clots. It is indicated in the treatment of acute symptomatic deep vein thrombosis with or without pulmonary embolism when administered with warfarin. 

TPA is also under clinical trials for the treatment of unstable angina, ischaemic stroke, acute stroke and pulmonary embolism. A major competitor of TPA is streptokinase, which is a bacterial enzyme. Hiis compound is cheaper and may be more effective than TPA in some respects although there is a higher risk of allergenic response. 

Although similar events complicate the utilization of bronchial artery embolization in patients with hemoptysis due to lung cancer and/or radiation changes, pulmonary hemorrhage is frequently an acute medical emergency which demands instant and effective treatment. 

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