Embolism

Faculty of Medicine Pa g e 1 o f 6 EMBOLISM Ain shams university Department of toxicology

Mohammed A. Ghanem

Edited BY/ Mohammed Ahmed Ghanem SUPERVISOR /DR. MARY

EMBOLISM EMBOLISM is a very common cause of sudden death that is misdiagnosed. Embolus is a free mass in the blood which can occlude any vessel at any time. The mass which is called a thrombus may be column of air or foreign body or fat globule...Etc. If it occludes an artery it will lead to tissue necrosis. If occlude a vein leading to tissue congestion and disturbance in organ function. Death occur suddenly due to right sided heart failure in general venous air embolism in arterial air embolism death due to migration of embolus to left ventricle to many organs (brain is fatal).diagnosis in most cases is lost. But we have certain investigation that is should be done e.g. ECG. Lines of treatment depend on the nature of the embolus but always thrombolytic embolus is the only one under control.

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Mohammed A. Ghanem

EMBOLISM

AIM OF THE RESEARCH    

To spot light on embolism as a cause of death. To spot light on different types of embolism. To spot light on PMP. Of died persons. To spotlight on Pathophysiology of embolism.

INTRODUCTION Embolism: an embolism occurs when an object migrates from one part of the body and causes a blockage of a blood vessel in another part of the body. We will discuss its causes & Pathophysiology then its treatment & investigation. But unfortunately it is always fatal.

CLASSIFICATION MA T E RI A L :

1. 2. 3. 4. 5. 6.

Thromboembolism – embolism of thrombus or blood clot. Fat embolism – embolism of fat droplets. Air embolism (also known as a gas embolism) – embolism of air bubbles. Septic embolism – embolism of pus-containing bacteria. Tissue embolism – embolism of small fragments of tissue. Foreign body embolism – embolism of foreign materials such as talc and other small objects. 7. Amniotic fluid embolism – embolism of amniotic fluid, foetal cells, hair, or other debris that enters the mother's bloodstream via the placental bed of the uterus and triggers an allergic reaction. P A T H WA Y :

1. Anterograde

2. Retrograde

3. Paradoxical

CAUSES & Pathophysiology A. Thromboembolism, This is when a part of a blood clot (thrombus) blocks blood flow to a major organ such as the heart or lungs. It’s the most common type of embolism.

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B. Fat embolism usually occurs when 

Endogenous : 1. The fracture of tubular bones (such as the femur), which will lead to the leakage of fat tissue within the bone marrow into ruptured vessels. 2. Trauma of burns of a fatty area.  Exogenous: (from sources of external origin) causes such as intravenous injection of emulsions.

C. Air embolism is usually always caused by exogenic factors.  the rupture of alveoli, and inhaled air can be leaked into the blood vessels.  the puncture of the subclavian vein by accident or during operation where there is negative pressure.  Air is then sucked into the veins by the negative pressure caused by thoracic expansion during the inhalation phase of respiration.  Intravenous therapy, when air is leaked into the system (however this iatrogenic error in modern medicine is extremely rare).  Gas embolism is a common concern for deep-sea divers because the gases in our blood (usually nitrogen and helium) can be easily dissolved at higher amounts during the descent into deep sea. However, when the diver ascends to the normal atmospheric pressure, the gases become insoluble, causing the formation of small bubbles in the blood. This is also known as decompression sickness or the Bends. D. Septic embolism happens when a purulent tissue (pus-containing tissue) is dislodged from its original focus. E. Tissue embolism is a near-equivalent to cancer metastasis, which happens when cancer tissue infiltrates blood vessels, and small fragments of them are released into the blood stream. F. Foreign-body embolism happens when exogenous—and only exogenous—materials such as talc enter the blood stream and cause occlusion or obstruction of blood circulation. G. Amniotic-fluid embolism is a rare complication of childbirth.

DIAGNOSIS & INVESTIGATION ECG

Embolism can be difficult to diagnose. But certain investigations should be done: CX-R Doppler ultrasound

V/Q scan

Arterial blood gas study

Pulmonary angiogram

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EFFECT of embolism & SYMPTOMS 1. Occlusion of an artery causing ischemia & tissue death. 2. Occlusion of a vein USUALLY SYMPTOMLESS but congestion may become symptomatic especially in vital organs.

A N E M B O L I S M I N A N A R T E R Y causes symptoms in the affected area and may include the following: pain, numbness, tingling, coldness, mottled or pale skin, and muscular spasms (twitches) or paralysis (unable to move).

A N E M B O L I S M I N A V E I N doesn't always cause symptoms. However, there may be: tenderness in the calf or upper leg, which may get gradually more painful, a mild fever, with the skin feeling hot in the area where the embolism is, swelling in one leg and not the other, redness of the leg, and swollen veins.

D E E P V E I N T H R O M B O S I S is an example of an embolism that forms in a vein in this case, a blood clot. If the blood clot breaks away, it can be carried in the bloodstream up to and through the heart, before entering one of the main arteries to the lungs. This can cause the following symptoms: chest pain, rapid heart beat, shortness of breath and fast breathing, and coughing (sometimes bringing up blood).

G E N E R A L L Y An embolism in an artery in the brain can cause a transient ischemic attack, or a stroke. An embolism in a coronary artery (an artery on the surface of the heart) can cause a heart attack.

A. Pulmonary embolism: The incidence of pulmonary embolism and the number of clinically missed diagnoses of it in necropsies carried out between 1960 and 1984 at this department were investigated. Pulmonary embolism primarily affects elderly people with serious underlying disease; in this study it was found more often in women. The incidence of pulmonary embolism (9% of all necropsies) was unchanged during the period studied. In contrast, pulmonary embolism as the "sole" cause of death increased (p less than 0.0005). Although most pulmonary emboli were the immediate cause of death, the clinical diagnosis was often missed (in 84% of all cases). Furthermore, such clinically missed diagnoses increased over the years (p less than 0.005), especially in patients with heart disease and cancer. W ithout necropsy there will be considerable under diagnosis of pulmonary embolism, therefore providing a misleading figure in the death statistics for this often fatal disease.

B. Brain embolism : Cerebral embolism (intracranial embolism). One of the most common causes of a stroke. It occurs when an embolus (usually a blood clot) becomes lodged in an artery in the brain, blocking oxygen-rich blood from nourishing the portion of the brain beyond the blocked artery. Without adequate oxygen, that area of the brain suffers tissue damage or death, causing typical stroke symptoms such as speech impairment, one-sided paralysis, or problems with comprehension or vision (depending on which portion of the brain was damaged).

C. Therapeutic embolism (embolization ): The deliberate creation of an embolus to obstruct a blood vessel in order to stop internal bleeding or to cut off the blood supply to a tumor.

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These man-made emboli can be made of many different materials, such as fibrin, metal coils, silicone balloons, wool or medicinal glue.

D. Paradoxical embolism . The result of an embolus that has traveled from the veins to the arteries to the brain (where it blocks a cerebral artery), or any other systemic artery. The embolism is “paradoxical” (contrary to the usual) because normally blood cannot travel from a vein into an artery. The condition can occur when an embolus crosses from the right side of the heart to the left side through a hole in the septum (the muscular wall that separates the left and right sides of the heart). The hole is usually the result of an unrepaired congenital heart defect (e.g., patent foramen ovale, atrial septal defect, ventricular septal defect).

E. Fat embolism , which can occur around 48 hours after a major bone fracture, include: Confusion, rash, sleepiness, rapid heart beat, breathlessness, and bluish tint to the skin (cyanosis).

F. Air embolism is a life-threatening emergency that will lead to the heart’s stopping (cardiac arrest) and sudden cardiac death if not treated immediately. A major cause of air embolisms are rapid ascents during deep-water dives. Symptoms usually appear very quickly after the ascent and may include: Dizziness Bloody froth from nose or mouth Paralysis Convulsions

POST MORTEM PICTURE Air embolism: 1 X-ray of chest: IV air bubbles. 2. Open the heart and pulmonary arteries under water. OTHERS: large once causes death with right sided heart failure. Smaller fat embolism causes delayed death with pulmonary edema pneumonia atelectasis.

TREATMENT OF EMBOLISM Arterial embolism requires prompt treatment at a hospital. The goals of treatment are to control symptoms and to improve the interrupted blood flow to the affected area of the body. The cause of the clot, if found, should be treated to prevent further problems. Medications include:  Anticoagulants (such as warfarin or heparin) can prevent new clots from forming  Antiplatelet medications (such as aspirin, ticlopidine, and clopidogrel) can prevent new clots from forming  Painkillers given through a vein (by IV)  Thrombolytics (such as streptokinase) can dissolve clots Some people need surgery. Procedures include:  Bypass of the artery (arterial bypass) to create a second source of blood supply  Clot aspiration (thromboaspiration)  Clot removal through a balloon catheter placed into the affected artery or through open surgery on the artery (embolectomy)  Opening of the artery with a balloon catheter (angioplasty) with or without a stent implanted

CONCLUSION & SUMMARY

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Mohammed A. Ghanem

EMBOLISM is a very common cause of sudden death that is misdiagnosed. Embolus is a free mass in the

blood which can occlude any vessel at any time. The mass which is called a thrombus may be column of air or foreign body or fat globule...Etc. If it occludes an artery it will lead to tissue necrosis. If occlude a vein leading to tissue congestion and disturbance in organ function. Death occur suddenly due to right sided heart failure in general venous air embolism in arterial air embolism death due to migration of embolus to left ventricle to many organs (brain is fatal).diagnosis in most cases is lost. But we have certain investigation that is should be done e.g. ECG. Lines of treatment depend on the nature of the embolus but always thrombolytic embolus is the only one under control.

REFERENCES 1. NHS. http://www.nhsdirect.nhs.uk/index.aspx?WT.svl=nav Title: Embolism

2. Principles of forensic medicine stuff members of forensic medicine & clinical toxicology department Ain Shams University.

3.

Wikipedia Embolism.

http://en.wikipedia.org/wiki/Embolism article title: