Pulmonary Embolism

What is Pulmonary Embolism (PE)?

PE refers to the obstruction of the pulmonary artery or one of its branches by a thrombus (blood clot) that originates in the venous system or the right side of the heart

Pathophysiology of PE

PE causes increased pulmonary artery pressure, increased dead space, increased right ventricular (RV) workload (can lead to RV failure), decreased cardiac output, and shock

Contributing Factors to PE - Endothelial Damage

Phlebitis, vascular disease, IVs, pacing wires, trauma, surgery

Contributing Factors to PE - Venous Stasis

Immobility, bedrest, varicosities, obesity, long bone fractures, advanced age over 50 years

Contributing Factors to PE - Altered Coagulation

Smoking, pregnancy, OCP or estrogen therapy, cancer, COVID-19, clotting disorders (Protein C/S deficiency, Factor V Leiden), history of DVT or PE

Clinical Manifestations of PE - Respiratory Symptoms

Sudden onset of dyspnea, pleuritic chest pain, tachypnea (most frequent sign), cough, hemoptysis

Clinical Manifestations of PE - Other Signs

Tachycardia, anxiety or apprehension, low-grade fever, diaphoresis, syncope

Diagnostic Test for PE - D-dimer

Elevated plasma D-dimer indicates possible clot formation

Diagnostic Test for PE - Chest CT with contrast

Gold standard imaging test to confirm PE

Diagnostic Test for PE - V/Q Scan

Ventilation/Perfusion scan used if CT is inconclusive

Diagnostic Test for PE - Pulmonary Angiography

Definitive test if other scans are inconclusive

Diagnostic Test for PE - Others

Chest X-ray, ECG, ABG, end-tidal CO2

Emergent Interventions for PE - Oxygen and Support

Administer oxygen, monitor respiratory rate, mechanical ventilation if needed

Emergent Interventions for PE - Pain and Anxiety

Administer opioids for anxiety and chest pain or discomfort

Emergent Interventions for PE - Monitor Vitals and Labs

Check O2 saturation, ABGs, CBC, electrolytes, BUN, coagulation studies

Emergent Interventions for PE - Fluids and Output

Treat hypotension with IV fluids, monitor intake and output, insert Foley catheter if needed

Thrombolytic Therapy for PE (Unstable PE)

Medications to lyse clots including Alteplase, Reteplase, Tenecteplase, and Urokinase

Anticoagulation Therapy for PE

Heparin (IV), Warfarin (oral), Low-Molecular-Weight Heparin (Dalteparin, Enoxaparin), Factor Xa Inhibitors (Fondaparinux, Rivaroxaban, Apixaban, Edoxaban, Betrixaban), Direct Thrombin Inhibitor (Dabigatran)

Heparin Dosing Example

Heparin 25,000 units in 250 ml D5W equals 100 units/ml

If ordered 750 units/hr, run at 7.5 ml/hr

Heparin Pump Calculation - 900 units/hr

900 units/hr divided by 100 units/ml equals 9 ml/hr

Heparin Therapy Monitoring

Goal PTT is 1.5 to 2 times normal

Antidote is protamine sulfate

Warfarin Therapy Monitoring

Goal INR is 2.0 to 3.0

Antidote is vitamin K

Patient Teaching for Anticoagulation Therapy

Take medication as prescribed at the same time daily, do not stop unless directed, wear a medical alert bracelet, maintain consistent intake of vitamin K foods, notify provider before surgery or dental work

Additional Patient Teaching for PE Medications

Keep all lab appointments, consult your doctor before taking OTC medications, avoid aspirin unless directed, monitor for signs of bleeding

Surgical Interventions for PE

IVC filter (Greenfield), embolectomy

Nursing Interventions for PE - Position and Oxygen

Sit patient upright, administer oxygen immediately

Nursing Interventions for PE - Medications

Start heparin right away, add warfarin early as it takes a few days to reach therapeutic levels

Prevention of PE - Mobility

Early ambulation, avoid prolonged sitting or lying down, use active or passive range of motion exercises

Prevention of PE - Devices and Hydration

Use pneumatic compression devices and ensure adequate hydration

Prevention of PE - Anticoagulants

Use anticoagulant therapy as prescribed, avoid aspirin unless approved, maintain consistent vitamin K intake

PE Patient and Family Teaching Overview

Educate about medication adherence, signs of bleeding, safe activity levels, and the importance of follow-up care