SymptomsComplaints

There are no symptoms that indicate a pulmonary embolism beyond any doubt or unequivocally. Symptoms can be: Many pulmonary embolisms, especially smaller ones, are asymptomatic and can only be detected with special examinations.

Tachycardia
Shortness of breath
Chest pain, especially when inhaling
Sudden outbreak of sweat
Cough
Fever
Feeling of tightness (more at: Pressure in the chest – These are the causes)
Sudden unconsciousness

How a pulmonary embolism manifests itself depends on various factors.

These include the size of the clot and the affected part of the lung, the residual blood supply to the affected part of the lung, the age and previous illnesses of the person affected. A small lung embolism can go completely unnoticed, especially in otherwise healthy people. The typical symptoms of larger pulmonary embolisms are sudden shortness of breath and an associated increase in breathing and heart rate.

These symptoms usually occur from one moment to the next. They are often accompanied by a great deal of anxiety, which can develop into a fear of death. A breath-dependent, relatively rapidly developing pain in the affected section of the lung or below the diaphragm is described in about 2/3 of patients with larger embolisms.

Another frequent sign of pulmonary embolism is coughing. Due to the death of lung tissue, the cough can also contain blood.If the heart performance is so severely impaired by the embolism that not enough blood is pumped through the body’s circulation, circulatory problems with sweating, trembling and possibly loss of consciousness occur. Due to the combination of oxygen deficiency and cardiac overload, larger pulmonary embolisms are life-threatening and can quickly lead to death if no therapy is initiated.

The majority of severe and fatal pulmonary embolisms are intermittent. Dizzy spells, fainting spells and tachycardia occur repeatedly over hours or days in the course of small lung embolisms. If the symptoms are interpreted correctly, a large pulmonary embolism can usually be prevented.

Pulmonary embolism is often difficult to detect because its symptoms are extremely unspecific and rarely occur together. The most important signs are shortness of breath and chest pain. These usually occur suddenly when the embolism is lodged in a pulmonary vessel.

In addition to shortness of breath, a so-called cyanosis can occur. This is expressed by a bluing of the mucous membranes (especially the lips) and possibly the fingers and is caused by a lack of oxygen. The oxygen deficiency caused by an embolism can also damage the heart.

In addition, a pulmonary embolism can increase the blood pressure in the pulmonary vessels. On the other hand, the heart has to pump harder, which is why it also consumes more oxygen. This combination can lead to cardiac insufficiency, increased pulse and a drop in blood pressure.

The combination of a drop in blood pressure and an increase in pulse rate indicates a state of shock and can also cause dizziness and sweating. Particularly unspecific signs can also be a dry cough or even a haemoptysis. Pain can occur in pulmonary embolisms, but is not very characteristic and is usually not the main symptom.

Their exact cause is not yet fully understood. In the beginning, there is usually a pain behind the breastbone, which can be confused with a heart attack. Over the course of days, the irritation of the pulmonary membranes usually leads to a different type of pain, the intensity of which depends on breathing.

If pneumonia occurs, the pain can become worse. It is important that other causes should be considered and clarified if the pain remains. Back pain is one of the possible symptoms of a pulmonary embolism.

It usually occurs in the area of the middle to upper back, where the pulmonary embolism irritates the lung membranes and can lead to pain. Back pain does not usually occur separately, but is accompanied by other symptoms such as shortness of breath or pneumonia. They occur relatively quickly and change their character within the next few days, so that the pain usually feels different as it progresses.

They often become stronger through inhalation and/or exhalation and should improve significantly after administration of painkillers. Coughing is a common, albeit very unspecific, symptom of pulmonary embolism. Especially smaller otherwise inconspicuous embolisms are expressed by a irritable cough.

Larger embolisms can also cause a bloody cough. The cough is caused on the one hand by the fact that the blood clot directly irritates the lungs. In addition, there is reduced blood circulation in the area behind the blocked vessel.

This can lead to inflammation in the area, which also causes a cough. In the worst case even pneumonia is triggered. Fever is a known complication of pulmonary embolism.

In most cases it does not occur immediately at the same time as the embolism. Instead, it makes itself felt some time later. In most cases, the trigger is a so-called infarct pneumonia, i.e. pneumonia that develops after a pulmonary infarction.

An infarction is a situation in which tissue is not sufficiently supplied with blood and thus suffers from a lack of oxygen and nutrients. This is triggered in the lungs by a blood clot. The undersupplied area is also called the infarct area.

Due to the lack of blood supply, an inflammation can develop there, which leads to symptoms such as fever. Night sweat is an extremely unspecific symptom, but in most cases this should be taken very seriously. One speaks of real night sweat when someone sweats so much at night that the pyjamas and bed linen must be changed.In the case of a pulmonary embolism, there are two possible triggers for night sweats: Firstly, the embolism can subsequently trigger pneumonia, which is accompanied by fever and chills.

However, older people in particular often do not develop a fever; instead, they suffer from night sweats. Heart failure caused by pulmonary embolism can also cause night sweats. Especially clots, which only close small vessels and are then quickly dissolved by the body, can go completely unnoticed or cause only slight discomfort.

These are often blamed by those affected on other causes. In themselves, unnoticed or only small pulmonary embolisms are not very dangerous – what is treacherous, however, is that you are often followed by other pulmonary embolisms that are larger and can become life-threatening. Therefore, if you suspect a pulmonary embolism, you should always consult a doctor.

It is assumed that about half of all pulmonary embolisms go unnoticed.

ECG
Doppler sonography of the heart
Pressure measurement in the pulmonary circulation
Perfusion scintigraphy of the lung with technetium-labeled albumin aggregates
Pulmonary is angiography (contrast center imaging of the pulmonary vessels)
Spiral CT
Digital Subtarctic Angiography (DSA)

Pulmonary embolism is different from case to case and also depends on the size of the vessels that are blocked. Patients who present have mild to severe breathing difficulties, including shortness of breath.

Other signs of pulmonary embolism may include a new cough, chest pain, dizziness, anxiety with sweating, and circulatory failure. An irregular heartbeat (cardiac arrhythmia) can also be an indication of pulmonary embolism. If a leg is new or recently swollen, reddened, painful and overheated, this may be a sign of leg vein thrombosis, which in conjunction with the other symptoms described above may indicate pulmonary embolism.

At admission, a simple questionnaire, the Wells Score, can be used to assess the risk of pulmonary embolism by asking standardized questions. Furthermore, a blood sample can be taken to confirm the suspicion of an increase in D-dimers (coagulation products). A CT scan or magnetic resonance imaging (MR angiography) of the pulmonary vessels, as well as a scintigraphy, can often identify an embolism.

In the lung perfusion scintigraphy, radioactive particles are injected into a vein; if a section of the lung is displaced by an embolus, this part of the lung is depicted without radioactive particles, as these cannot get there via the occluded vessel. Other diagnostic tools include cardiac ultrasound (echocardiography), ECG and chest x-ray. In the event of a pulmonary embolism, changes in the ECG are evident in between a quarter and half of the patients.

This figure shows that the ECG as a diagnostic tool is not very meaningful here and has a low sensitivity. In other words, if the ECG is unremarkable, a large number of patients will still have a pulmonary embolism. It may be helpful for the attending physician to have an older ECG that was taken before the suspicion or symptoms of a pulmonary embolism were suspected.

In comparison with the “fresh” ECG, individual changes in the patient can be seen and described more clearly. The basis for the change in the ECG in the case of a pulmonary embolism is that the volume and pressure of the right heart is increased. Due to the embolism of the pulmonary vessels, the resistance in the lungs increases and the right heart must apply more force to pump the blood into and through the lungs.

Due to the increased load on the right heart, the ECG shows a right heart type. Other changes in the ECG may include the formation of a S1Q3 configuration (S-wave in lead I and Q-wave in lead III), T-negativation of leads V1-3, and an incomplete to complete right thigh block. These changes are partially differently pronounced and visible.

Therefore, the diagnosis and evaluation of an ECG should only be performed by a physician. Computer tomography, or CT for short, is the most important examination nowadays when pulmonary embolism is suspected.By imaging the vessels of the lung and, if present, the clot inside them in a so-called CT angiography, it is possible to assess very well whether or not a pulmonary embolism is present. If the doctors do not see any clots in the pulmonary vessels during this examination, it can be said with great certainty that the symptoms are not caused by pulmonary embolism.

It is important that contrast medium must be injected into a vein during a CT angiography, as only then can the vascular system be depicted well. The contrast medium usually contains iodine and can trigger an allergic reaction and hyperthyroidism. Therefore, it must be known before the examination whether a known allergy to contrast medium or hyperthyroidism exists.

D-dimers are proteins that are released into the blood when coagulated blood dissolves. A simple wound where the blood then coagulates and is broken down after some time can therefore cause even slightly increased D-dimers. However, thrombi (blood clots) that are located inside a blood vessel are also broken down over time and can release D-dimers.

These proteins are therefore an important blood value for ruling out pulmonary embolism. Since the causes of elevated D-dimer levels are manifold, a high D-dimer value does not necessarily mean that a pulmonary embolism is present. Conversely, a negative value (no detection of D-dimers) can rule out pulmonary embolism.

In the pulmonary embolism score, patients are divided into risk groups based on various parameters. The points can be calculated from the following factors: For age, the number of years of life is given as points. The points for male gender (10 points), cancer (30 points), heart failure = heart failure (10 points), pulse above 110 beats per minute (20 points), systolic blood pressure = first blood pressure value below 100 mmHg (30 points), respiratory rate above 30 per minute (20 points), body temperature below 36°C (20 points), reduced state of consciousness (60 points) and oxygen saturation below 90% (20 points) are added together.

For patients with less than 85 points the risk of death is low. Above that, there is an increased risk. Stage classification of pulmonary embolism.

Four degrees of severity are classified.

Stage I: mildClinic: only short-term or no symptoms. Circulatory failure: < 25%
Stage II: moderateClinical: slight shortness of breath and accelerated pulse.
Circulatory failure: 25% – 50%
Stage III: massiveclinic: severe shortness of breath, collapse. Circulatory failure: > 50%.
Stage IV: high-gradeClinical: as stage III and additionally shockCirculation loss: > 50%

The symptoms of bilateral pulmonary embolism are in principle the same as those of unilateral pulmonary embolism. However, because both lungs are affected, they can be much more severe.

Here too, the severity depends on the size of the affected vessels in the respective lung. Only in the clinic can imaging examinations show which vessels are blocked by the clot and whether only one or both lungs are affected. The subsequent therapy then depends mainly on the severity of the pulmonary embolism and the patient’s condition.