PE

Massive

• Sustained hypotension
(<90 SBP x 15 minutes or inotrope use)
• Pulselessness
• Persistent Profound Bradycardia
(<40 bpm with s/s shock)

Submassive: RV dysfunction or Myocardial necrosis

Acute PE without hypotension but with:

RV dysfunction:

• RV dilatation RV:LV diameter >0.9 in A4C/CT or RV systolic dysfxn in echo
• BNP >90 pg/mL or NT pro BNP >500
• ECG: (new RBBB, anteroseptal STE, STD or TWI)

Myc Necrosis: TnI >0.4ng/mL, TnT >0.1

Low-risk PE: not massive, not submassive

Massive: heparin + alteplase (100mg x 2 hrs IV or in cardiac arrest: 50mg IV bolus then another 50mg IV bolus after 15 mins if no ROSC)

Submassive: heparin +/- alteplase

*alteplase if shock/respiratory distress or mod-severe respiratory distress

shock or respiratory distress

• <90mmHg
• SI >1
• SaO2 <95% with Borg score >8
• AMS
• appearance of suffering

mod-severe respiratory distress

• RV hypokinesis, interventricular septal shift or bowing, or est. RVSP >40 mmHg
• clearly elevated cardiac markers
, TnT above borderline, BNP >100 pg/mL or NTpBNP >900

Low-risk: clexane 1mg/kg or heparin

Thrombolysis c/i:

Absolute c/i

- prior ICH

- known intracranial CVD (AVM)

- known malignant IC neoplasm

- ischaemic stroke within 3 months

- suspected aortic dissection

- active bleeding or bleeding diathesis

- recent surgery encroaching on spinal canal or brain

- recent significant closed-head or facial trauma with radiographic evidence of bony fracture or bony injury

Relative c/i

>75yo

- use of anticoagulation

- pregnancy

- non compressible vascular punctures

- traumatic or prolonged CPR (>10 minutes)

- recent internal bleeding (within 2-4 weeks)

- hx of chronic, severe, and poorly controlled HTN

- severe uncontrolled HTN on presentation >180/>110)

- dementia

- remote (>3 months) ischaemic stroke

PE Algorithm

Circulation 2011 -- Management of Massive and Submassive PE, Iliofemoral DVT, and Chronic TE Pulmonary Hypertension

- major surgery within 3 weeks

Atypical Pneumonia

1. Chlamydia
2. Mycoplasma
3. Legionnaire's

All are not seen in Gram Stain

All are treated with Macrolide (Azithromycin)

What is PEEP?

Q: What is PEEP?
A: It is the alveolar pressure above atmospheric pressure at the end of expiration.

Two types:
1) Intrinsic or auto PEEP
2) Extrinsic or applied PEEP: set on mechanical ventilator
3-5 cmH2O: called physiologic PEEP, indicated for most patients undergoing mechanical ventilation. This mitigates end-expiratory alveolar collapse, a consequence of the endotracheal tube bypassing the glottic apparatus

Wiki Link
UpToDate Link

Pneumothorax vs Bulla

Q: What is the difference between Bulla and Pneumothorax?
A:
1) History:

• Bulla in 2 distinct populations:
  (1) emphysematous COPD (smoker)
  (2) congenital (younger, non smoker)
  
• Long duration of symptoms = Bulla
  

2) CXR:

• Vascular markings seen through "pneumo" area
• Non-anatomic contour of the pleural line; bleb
  
• Old CXR comparison

If in doubt, do Chest CT. Bedside US can also differentiate [Simon BC et al. JEM (2005) 29:201-5], plus anterior pneumothorax in the initial evaluation of the trauma patient may be detected where supine AP films miss it.

Treatment for large bulla is surgical removal with pleurodesis. It may enlarge after needle aspiration or chest tube drainage.

credit:
Swadron, Mastering Chest Radiography, ACEP lecture.