Pulmonary embolism

Pulmonary embolism

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

dislodged or fragmented DVT

PE is due to a

• Air

• Fat

• Amniotic fluid

• Septic

other types of emboli that may be implicated:

bacterial invasion

Septic is from _____ _____ of the thrombus

outflow tract

A PE is described as an occlusion of the ____ tract of the main pulmonary artery or of the bifurcation of the pulmonary arteries.

ischemic necrosis

Multiple small emboli can lodge in the terminal pulmonary arterioles, producing multiple small infarctions of the lungs. A pulmonary infarction causes _____ ____ of part of the lung (Thompson & Kabrhel, 2020).

iliac, femoral, and popliteal veins

The majority of thrombotic emboli arise from the deep leg veins, particularly the ____, _____, and ____ veins

1 hour

death from acute PE commonly occurs within __hour after the onset of symptoms;

90%

__% of fatalities occur within the first 1-2 hours.

Fat emboli

most common thrombotic emboli; may occur after long bones fracture (typically the femur) releases the bone marrow fat into the circulation.

• increased alveolar dead space

• bronchoconstriction

• compensatory shunting

The effects on the pulmonar system are: IBC

bronchoconstriction

Increased alveolar dead space

This effect leads to alveolar dead space ventilation and an increase in the work of breathing. To limit the amount of dead space ventilation, localized _____ occurs.

alveolar hypocarbia, hypoxia, and the release of mediators.

Bronchoconstriction develops as a result of _______, ____, and _____

Alveolar hypocarbia

occurs as a consequence of decreased carbon dioxide in the affected area and leads to constriction of the local airways, increased airway resistance, and redistribution of ventilation to perfused areas of the lungs.

atelectasis

Bronchoconstriction promotes the development of ____

atrial fibrillation

____ _____ can also cause PE

right atrium

An enlarged ___ ____ in fibrillation causes blood to stagnate and form clots in this area may travel into the pulmonary circulation

Massive PE

It is described as an occlusion of the outflow tract of the main pulmonary artery or of the bifurcation of the pulmonary arteries

cardiopulmonary failure

Massive PE can lead to acute and severe _______ ______ from r ventricular overload.

• Sustained hypertension

• Pulselessness

• Persistent bradycardia

Massive PE is characterized by SPP

Restlessness

Cardinal initial sign of PE

size and area

Symptoms of PE depend on the ___ of the thrombus and the __ of the pulmonary artery occluded by the thrombus; may be nonspecific; usually develop abruptly or over a period of minutes

• Dyspnea

• Tachypnea

• Confusion

• Delirium

• Decrease LOC

• Petechiae

Signs and symptoms of FAT emboli: DTC DDP

Homan’s sign

ask the patient to extend knee; once extended the examiner raises the patient straight leg to 10° passively and abruptly dorsiflex the foot and squeeze the calf with the other hand.

indicates DVT

Deep calf pain and tenderness

Obstruction of the pulmonary artery

can result in pronounced dyspnea, sudden substernal pain, rapid and weak pulse, shock, syncope, and sudden death (Thompson & Kabrhel, 2020).

Blood Coagulation Studies

ordered to provide a baseline to institute anticoagulation therapy and monitor patient’s response.

aPTT(Activated Partial Thromboplastin Time) and PTT (Partial Thromboplastin Time

– to assess intrinsic clotting pathway

PTT

useful to evaluate response to heparin therapy

60-70 sec

PTT N. V

30-40 sec

aPTT N.V.

Prothrombin Time (PT)

to assess extrinsic clotting system – to evaluate response to Coumadin (Warfarin)

10-12 sec

Prothrombin Time N.V

D Dimer

to determine for massive clot breakdown rather than lack of clotting factors; to determine for DIC

0-0.50mg/L

D Dimer N.V

Lung scan

provide more reliable evidence of PE

V/Q scan

it is possible to identify areas of the lungs that are ventilated but not perfused

Multidetector-row computed tomography angiography (MDCTA)

is the criterion standard for diagnosing PE - provides the advantage of high-quality visualization of the lung parenchyma

Pulmonary angiography/ Pulmonary arteriography

Gold standard to diagnose PE but too invasive

alternative diagnostic study

allows for direct visualization under fluoroscopy of the arterial obstruction and accurate assessment of the perfusion deficit.

Venography

most accurate diagnostic tool for DVT; an xray study used to identify and locate thrombi in the veins of the lower extremities; it is invasive and can potentially cause clot formation.

1. Active leg exercises to avoid venous stasis

2. Early ambulation

3. Use of anti-embolism stockings

Prevention of PE:

STAT

Nasal oxygen is given immediately (___)- to relieve hypoxemia, respiratory distress, and central cyanosis

Emergent endotracheal intubation and mechanical ventilatory

management for severe hypoxemia

vasopressor therapy

For hypotension that does not resolve with IV fluids: prompt administration of ______ _____(dobutamine, dopamine, or norepinephrine) via infusion pump.

respiratory depression

When taking morphine, monitor for ______ _____

Stop the medication

When taking morphine:
If RR = <12

What will you do as a nurse?

Anti-embolic stockings or intermittent pneumatic leg compression devices

reduces venous stasis.  These measures compress the superficial veins and increase the velocity of blood in the deep veins by redirecting the blood through the deep veins.

Anticoagulation therapy

the standard treatment to prevent pulmonary emboli

Immediate anticoagulation

is indicated to prevent a reoccurrence or extension of the thrombus and may continue up to 10 days

1000 – 15000 U/H

Heparin initiated IV bolus of 5000-10,000 U followed by continuous infusion at a rate of ____

2 weeks

Heparin for __ weeks

Protamine sulfate

Antidote of Heparin

vit. K

Antidote of warfarin

10 days to 3 months

Long-term anticoagulation is also indicated from ______ following the PE and is critical in the prevention of recurrence of VTE.

thrombolytic therapy

NOACs are contraindicated in patients who may receive _____ ______ because their safety and efficacy are unknown in hemodynamically significant PE.

hemodynamically unstable

Unfractionated heparin is preferred in patients who are ______ _______ in anticipation of a potential need for thrombolysis or embolectomy.

• Warfarin

• NOACs

Long-term treatment options include:

3 - 6 months

Warfarin – given for at least _____ months

subcutaneous

Low molecular weight heparin may also be indicated but is usually not prescribed for long term therapy since it is given via a ______ injection.

Thrombolytic therapy

used in patients with an acute PE who have hypotension and do not have a contraindication or potential bleeding risk

resolves the thrombi or emboli quickly and restores more normal hemodynamic functioning of the pulmonary circulation, thereby reducing pulmonary hypertension and improving perfusion, oxygenation, and cardiac output

• INR

• PTT

• Hematocrit

• Platelet counts

Before thrombolytic therapy is started, _____ are obtained

Surgical Embolectomy

is rarely performed but may be indicated if the patient has a massive PE or hemodynamic instability or if there are contraindications to thrombolytic (fibrinolytic) therapy.

catheters or surgically

Embolectomy can be performed using ______ or _____

percutaneous transjugular route

In catheter embolectomy,
An insertion of umbrella like filter into the inferior vena cava via _______ ________ ____ – trap an enlarged emboli allowing blood flow through the inferior vena cava.