What is the management approach for a patient with Hampton hump suggestive of pulmonary infarction due to pulmonary embolism?

Management Approach for Hampton Hump in Pulmonary Embolism

For patients with Hampton hump suggestive of pulmonary infarction due to pulmonary embolism, immediate anticoagulation with intravenous heparin (80 units/kg) should be initiated, followed by risk stratification to determine the need for thrombolytic therapy in hemodynamically unstable patients. 1

Initial Assessment and Risk Stratification

• Assess clinical state immediately to determine severity of PE: cardiac arrest, deteriorating condition, or stable condition 1
• Check for signs of massive PE: collapse/hypotension, unexplained hypoxia, engorged neck veins, and right ventricular gallop 1
• Evaluate hemodynamic stability - this is the primary determinant of management approach 1
• Consider clinical prediction scores (Wells' rule or Revised Geneva score) to confirm PE probability 1
• Hampton hump on chest radiograph represents a pleural-based area of increased opacity indicating pulmonary infarction, which is associated with more severe PE and increased mortality risk 2

Management Algorithm Based on Clinical State

For Hemodynamically Unstable Patients (Cardiac Arrest/Shock):

• Initiate CPR if in cardiac arrest 1
• Administer 50 mg alteplase IV immediately 1
• Reassess after 30 minutes 1
• For deteriorating patients, contact consultant immediately and administer 50 mg alteplase IV 1
• In stable patients with confirmed massive PE, administer 100 mg alteplase over 90 minutes 1
• Follow thrombolysis with unfractionated heparin after 3 hours, preferably weight-adjusted 1

For Hemodynamically Stable Patients:

• Administer 80 units/kg heparin IV immediately 1
• Arrange urgent echocardiography or CTPA if deterioration occurs 1
• Consider outpatient treatment only if the patient is not unduly breathless, has no medical or social contraindications, and an efficient protocol is in place 1
• For long-term management, consider direct oral anticoagulants like rivaroxaban for treatment of PE 3

Special Considerations for Pulmonary Infarction (Hampton Hump)

• Patients with Hampton hump have higher likelihood of rider-type embolism, pleural effusion, and dilation of pulmonary arteries 2
• The presence of Hampton hump with pleural effusion substantially increases the risk of in-hospital death 2
• Monitor closely for complications of pulmonary infarction including pain, pneumonia, and post-PE syndrome 4
• The infarcted area is replaced by fibrotic scar over months, requiring follow-up imaging 4

Important Caveats and Pitfalls

• Hampton hump is not specific to PE - it can also be seen in septic emboli from endocarditis 5, 6
• Chest radiograph alone has poor sensitivity and specificity for PE diagnosis - the main value is to exclude other diagnoses 7
• Avoid initiating rivaroxaban acutely as an alternative to unfractionated heparin in hemodynamically unstable PE patients 3
• Do not delay transfer of unstable patients for additional imaging studies 1
• In life-threatening PE, contraindications to thrombolysis should be ignored 1
• Do not rely solely on D-dimer testing in patients with high clinical probability of PE or probable massive PE 1

By following this structured approach based on hemodynamic stability and recognizing the significance of Hampton hump as a marker of potentially more severe disease, clinicians can optimize management of patients with pulmonary infarction due to pulmonary embolism.