OzEMedicine - Wiki for Australian Emergency Medicine Doctors

see also historic perspectives of medicine, pulmonary embolism (PE), historical perspectives of anticoagulant Rx

• 11th C: death due to “sudden breathless sleep” found to be due to thrombus in pulmonary vessels
• 1846: classic triad of venostasis, hypercoagulability & vessel wall inflammation causing DVT was worked out by von Virchow who also was the 1st to show that pulm. arterial thrombus 1st develops in deep veins of extremities. He coined the term embolism to describe this phenomenon. He also demonstrated anatomic anastomoses of bronchial arteries with which he explained the reason for failure of infarction to occur in all cases of PE.
• 1873: Bergmann recognised fat embolism in trauma pts
• 1891: 1st report of inhaled oxygen saving a person's life from PE
• early 1900's: Trendelenberg conceived & popularised procedures for pulm. thromboembolectomy & for vena caval interuption, but operative mortality (almost 100%) same as disease mortality
• 1924: Kirschner performed 1st pulmonary embolectomy with survival (not done in USA until 1958!)
• 1930's: heparin introduced & radically changed Mx of PEs from surgical (despite its ~100% mortality) to medical
• 1930's: streptokinase discovered
• 1951: urokinase discovered
• mid-1960's: perfusion lung scans developed
• late 1960's & early 1970's: 2 large clinical trials demonstrated benefits of thrombolysis if haemodynamically unstable
• pre-1970: it was thought that a pO2 > 80mmHg excluded PE & such pts were excluded from PE trials!
• 1970's: V/Q lung scans developed, dramatically changing diagnostic approach to PE
• 1977: USA FDA recommends SK protocol: 250,000U load/30min then 100,000U/hr for 24hrs
• 1978: USA FDA recommends urokinase protocol: 4,400IU/kg load/10min then, 4,400IU/kg/hr for 12-24hr
• 1990: PIOPED study published
• 1990: thrombolytics shown to decrease long term (7yr) pulmonary artery pressures in 23 randomised pts with PEs
• 1990: USA FDA recommends r-tPA protocol: 100mg over 2hrs
• 1992: thrombolytics shown to reduce 1 yr mortality from PEs from 19% with heparin alone to 8.7% in 399 pts
• 1997: helical multi-slice CT scanners becoming widespread allowing use in Dx of PE