Pulmonary Embolism

Pulmonary Embolism

•Obstruction of the pulmonary artery or one of its branches by a thrombus/clot

•Originates somewhere in the venous system or in right side of heart

•Deep vein thrombosis (DVT) is a related condition

•Venous thromboembolism: includes both DVT and PE

incidence of PE

•VTE related deaths: 300,000 annually

•34%: sudden and fatal

•59%: PE undetected until autopsy

Etiology of PE can be

-endothelial damage

-venous stasis

endothelial damage

•Trauma

•Surgery

•Pacing wires

•Central venous catheters

•Dialysis access catheters

•Local vein damage

venous stasis

•Bedrest/immobilization

•Obesity

•History of varicosity

•SCI

•Age > 65 years

altered coagulation can be from

•Cancer

•Pregnancy

•Oral contraceptive use

•Protein C or S deficiency

•Antiphospholipid antibody syndrome

•Factor V Leiden defect

•Polycythemia

•Sepsis

PE pathophysiology •Due to: Blood clot or thrombus

•Less common

•Fat emboli

•Air emboli

•Septic emboli

•Amniotic fluid (80-90% mortality rate)

pathophysiology of PE

•Thrombus completely or partially obstructs pulmonary artery or its branches

•Alveolar dead space increased

•Continues to be ventilated but receives little to no blood flow

•Impaired gas exchange

•Substances released that cause vasoconstriction→ increased pulmonary vascular resistance

WHO IS AT RISK FOR PE

-obstetrics

-bed bound

-older patients

-travel long distances

•Ventilation-perfusion imbalance PE pathophysiology

•Increased pulmonary resistance→ increased pulmonary arterial pressure→ increased right ventricular failure→ decreased cardiac output→ SHOCK!!

•A-fib may also cause PE

•Pulmonary infarction causes ischemic necrosis of lung

Clinical Manifestations

•Symptoms depend on size of the thrombus and location or pulmonary artery occluded

•Symptoms may be non-specific

•Dyspnea is most frequent symptom

•Chest pain-SUDDEN

CHEST PAIN

•Pleuritic in origin

•Sudden onset

•May mimic MI, angina, bronchopneumonia or heart failure

CM of PE

•Anxiety

•Fever

•Tachypnea

•Tachycardia

•Apprehension

•Cough

•Diaphoresis

•Hemoptysis

Syncope

•Massive PE

•Hemodynamic instability

•Shock

•Sudden death

How long does it take to die

•Death common in 1 hour after onset of symptoms

•Early recognition and diagnosis are priority

what helps you rule out other things

•Chest x-ray helpful in excluding other etiologies

•EKG

Gold standard doe PE

•Pulmonary angiography (gold standard)

-spiral CT

first we do CT but if patient is allergic next best

Ventilation-perfusion scan (IV contrast) ® for pts allergic to iodine

If somebody is crashing how do we test them

-spiral CT (of the chest)

blood work

-ABG

-D-dimer

How do we check for ventilation and perfusion

VQ scan

prevention PE

•Stratified by Risk

•Prevent deep vein thrombosis

•Anticoagulant therapy

•Prevent deep vein thrombosis

•Early ambulation

•Active leg exercises

•Elastic compression stockings

•SCD

•Anticoagulant therapy

•Low dose heparin

•Low-molecular weight heparin

Emergent Management

•Oxygen

•IV infusion lines

•EKG: dysrhythmias

•Perfusion scan

•Hemodynamic monitoring

•EKG/Continuous ECG

•Blood work

•ABG

•Intubation/Mechanical Ventilation

•Foley catheter

•Pharmacologic Management FOR

•Hypotension:

•Dobutamine, Dopamine, Levophed

•Small doses IV morphine, sedatives

Anticoagulation Therapy

•Three phases

•Initial phase

•Early maintenance phase

•LMWH/Arixtra/IV heparin x 5 days with overlapping Coumadin

•Prevents extension of thrombus

•Prevents development of new thrombi

•Long-term secondary phase

•3-6 months regimen of long-term based on risk of reoccurrence and bleeding

Unfractionated Heparin

•Heparin

•SQ to prevent

•IV continuous using weight-adjusted dosing guidelines

•Measure aPTT, platelet count

•In conjunction with Vitamin K antagonist IV heparin x 5 days with overlapping Coumadin

•Measure INR

LMWH

•Lovenox

•1 or 2 SQ doses/day

•Longer ½ life

•Dosed according to weight

•Less risk of Heparin induced thrombocytopenia (HIT)

Factor Xa Inhibitors

•Arixtra

•No effect on aPTT-> routine monitoring not necessary

•Pradaxa

•aPTT may be prolonged to 1.5-2 times

•Xarelto

THROMBOLYTICS

•Alteplase

•Given within first 3 days

•Lyses and dissolves thrombi

Contraindications to Therapy

•Patient history of non-adherence

•Bleeding (GI, respiratory, GU, reproductive)

•Hemorrhagic blood dyscrasias

•Aneurysms

•Severe trauma

•Alcoholism

•Recent or impending surgery of the eye, spinal cord or brain

•Severe hepatic or renal disease

•Recent CVA

•Infections

•Open ulcerative wounds

•Occupations that involve a significant hazard for injury

•Recent childbirth

Surgical Management

•Surgical embolectomy is rarely performed but indicated if patient has massive PE or hemodynamic instability

•Surgical: Cardiovascular surgical team required

•Transvenous catheter embolectomy

•Inferior vena cava (IVC) inserted at time of surgery

PATIENTS WHO COMMONLY GET PE OR DIAGNOSED W PE THEY GET A

•Inferior vena cava (IVC) inserted at time of surgery

NURSING PROCESS

•Minimizing risk of PE

•Preventing thrombus formation

•Assessing for potential PE

•Monitoring thrombolytic therapy

•Managing oxygen therapy

•Relieving anxiety and pain

•Monitoring for complications

•Post-operative monitoring

•Home education