Pulmonary Embolism (cont.)
Benjamin Wedro, MD, FACEP, FAAEM
Dr. Ben Wedro practices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, Wisconsin. His background includes undergraduate and medical studies at the University of Alberta, a Family Practice internship at Queen's University in Kingston, Ontario and residency training in Emergency Medicine at the University of Oklahoma Health Sciences Center.
George Schiffman, MD, FCCP
Dr. Schiffman received his B.S. degree with High Honors in biology from Hobart College in 1976. He then moved to Chicago where he studied biochemistry at the University of Illinois, Chicago Circle. He attended Rush Medical College where he received his M.D. degree in 1982 and was elected to the Alpha Omega Alpha Medical Honor Society. He completed his Internal Medicine internship and residency at the University of California, Irvine.
Melissa Conrad Stöppler, MD
Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
In this Article
- Pulmonary embolism facts
- What is a pulmonary embolism?
- What are the causes and risk factors for pulmonary embolism?
- What are the signs and symptoms of pulmonary embolism?
- How is pulmonary embolism diagnosed?
- History and physical examination
- Basic testing (CBC, electrolytes, BUN, creatinine blood test, chest x-ray, EKG)
- Pulmonary angiogram
- d-Dimer blood test
- CT Scan
- Ventilation-perfusion scans
- Venous Doppler study
- Echocardiography (EKG, ECG)
- What is the treatment for pulmonary embolism?
- Anticoagulation
- Thrombolytic therapy
- What is the prognosis for pulmonary embolism?
- Can pulmonary embolism be prevented?
Anticoagulation
The first step in stable patients with pulmonary embolism is anticoagulation. This is a two step process. Warfarin (Coumadin) is the drug of choice for anti-coagulation. It is taken by mouth beginning immediately upon the diagnosis of pulmonary embolism, but may take up to week for the blood to be appropriately thinned or anticoagulated. As an immediate solution and as a bridge until the Coumadin becomes effective, low molecular weight heparin (enoxaparin (Lovenox) or pentasaccharide (Fondaparinux, Arixtra) is administered at the same time. It thins the blood via a different mechanism. Enoxaparin or Fondaparinux injections can be administered as an outpatient.
For those patients who have contraindications to the use of enoxaparin (Lovenox) (for example, kidney failure does not allow the drug to be metabolized), intravenous heparin can be used as the first step. This requires admission to the hospital and careful patient monitoring with blood tests.
Anticoagulation is usually suggested for a minimum of six months, but each patient will have their treatment regimen individualized. The blood test utilized to monitor warfarin therapy is referred to as the INR or international normalized ratio. This test can be performed by finger stick or venous stick depending on the laboratory procedures. Essentially, this ratio is determined by measuring the patients prothrombin time, a test of blood thinness. This value is divided by the lab standard normal value. For patients with a pulmonary embolism, the warfarin dosing will be titrated so that the INR value will be 2.0 – 3.0, basically the blood needs to be 2 to 3 times thinner than the normal value. It is very helpful for the patient to participate in their health management by keeping a diary of their warfarin dose, the date of testing, and their INR values.
Next: Thrombolytic therapy
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