Pulmonary Embolus versus Right Ventricular Infarction

OVERVIEW

  • features that distinguish PE from RV infarction

COMPARISON TABLE

Table created by Chris Poynter

123
RV infarctAcute PE
History
  • Known IHD or family history
  • Previous MI
  • Diabetes
  • Smoker
  • Hypercholesterolaemia
  • Hypertension
  • Related to Virchow triad:
  • – venous stasis
  • – vessel injury
  • – hypercoagulability
Eg. Immobility, obesity, surgery, trauma, fractures, pregnancy, drugs eg. OCP, malignancy
symptoms
  • Cardiac chest pain eg. Central with radiation to jaw/arm
  • Can be atypical e.g. epigastric, back pain
  • +/- N&V, sweating, collapse, SOB
  • Silent/asymptomatic
  • Usually acute dyspnoea
  • Pleuritic chest pain
  • Haemoptysis/Cough
  • DVT/calf pain or swelling preceding
Examination
  • Lungs more likely to be clear
  • Arrhythmias common — esp bradyarrythmia eg. Complete heart block
  • Diaphoresis
  • Low Pulmonary pressures on PAC
  • Lung crackles/rales
  • Loud P2, Pulmonary hypertension on PAC
  • Cyanosis
  • Fever
  • Tachypnoea, hypoxia/increased FiO2
  • Calf swollen, tender, red
Investigations
bedsideECG – classic inferior/posterior MI changes with ST elevation in inferior leads and V4R, evidence of heart blockECG – Tachycardia, S1Q3T3ABG – hypoxia, increased A-a gradient, hypocapnia
laboratoryRaised troponin, CK, CKMBTroponin may be raised but lesser degree
radiological
  • CXR may be clear
  • Echo – regional wall motion abnormalities, Inferior LV hypokinesis
  • CXR – 80% show abnormailities eg. Pleural effusion, atelectasis, pulm. Infiltrates, Hampton’s hump, Westermark’s sign
  • Echo – evidence of pulmonary hypertension, McConnell’s sign (apical sparing of RV akinesis)
  • CTPA – shows to segmental level which should be adequate if presenting as RV failure
special testsAngiogram – blocked RCA (right dominant)
  • Pulmonary angiogram gold standard for diagnosis
  • V/Q scan may help if other options

References and Links

  • Ginghina C, Caloianu GA, Serban M, Dragomir D. Right ventricular myocardial infarction and pulmonary embolism differential diagnosis–a challenge for the clinician. J Med Life. 2010 Jul-Sep;3(3):242-53. PMC3019007.

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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