PULMONARY EMBOLISM Presented by:Lizawati binti Abu Bakar ADNS Emergency Nursing

Content
Important Terms What is Pulmonary Embolism Pathophysiology Risk Factors Clinical Manifestation Complication Laboratory Investigation Medication and Treatment Emergency Treatment Personal Data Past Medical Problem Medical History Nursing Diagnosis and Intervention Conclusion References

Introduction

In United State, Pulmonary Embolism occurs in more than 600,000 patients annually. Often pulmonary embolism is not accurately diagnosed and is found only on autopsy after unexpected death. It is contributes to 50,000 to 200,000 deaths per year and 2/3 of patients with fatal cases will die within one hour of presentation, thus it is a medical emergency.(Woods et al, 2005).

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In Malaysia, 252 death at 1991 due to Pulmonary Embolism 37 death attributed to obstetrical pulmonary embolism and 15 death due to amniotic fluid embolism (J.Ravindran 1991,Sudden Maternal Death due to Obstetrical Pulmonary Embolism in Malaysia.

Important Terms

Emboli

Thrombosis Deep vein thrombosis Pulmonary embolism

EMBOLI Clots or other substances that travel through the blood stream and get stuck in a blood vessel, blocking circulation.

Thrombosis The development of a blood clot inside a blood vessel.

Deep vein thrombosis The development of a blood clot in the calf's deep vein. This frequently leads to pulmonary embolism if untreated.

Pulmonary embolism
Pulmonary embolism is caused by emboli that travel through the blood stream to the lungs and block a pulmonary artery. When this occurs, circulation and oxygenation of blood is compromised. The emboli are usually formed from blood clots but are occasionally comprised of air, fat, amniotic fluid, tumor tissue, or particulate matter from intravenous injection, etc.

How Does Pulmonary Embolism Occur

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Summary of Pathophysiology of Pulmonary Embolism

Lung tissue is ventilated but not perfused because of block by emboli

Producing an intra pulmonary dead space and resulting in impaired gas exchange

The alveolar collapse and worsen hypoxemia

Lead to reduction in the cross sectional area of the pulmonary arterial bed Result in an elevation pulmonary arterial pressure and reduction in cardiac output

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The area of lung that is no longer perfused by the pulmonary artery may infarct

Picture of effect of the emboli in the pulmonary

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Risk Factors
Prolonged immobility or bed rest

Trauma including hip and femur fractures

Surgery (orthopedic, pelvic and gynaecology surgery Myocardial infarction and congestive heart failure,

Obesity and advanced age

Women who use oral contraceptive or estrogen therapy Women during pregnancy and childbirth

Family history
Previous blood clots (Rudolf Virchow Triad,1858)

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Summary of Risk Factor

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Clinical Manifestation for Pulmonary Embolism

Shortness of breath Chest pain. Feel like having a heart attack.

Cough. The cough may produce bloody or blood-streaked sputum.

Wheezing Leg swelling, usually in only one leg

Clammy or bluish-colored skin

Excessive sweating Rapid or irregular heartbeat

Weak pulse

Lightheadedness or fainting

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Complication of Pulmonary Embolism

sudden death. pulmonary infarction with necrosis.

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Laboratory Investigation
Chest X-ray: A Hampton hump in a person with a right lower lobe pulmonary embolism

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ECG: The classic signs are a large S wave in lead I, a large Q wave in lead III and an inverted T wave in lead III (S1Q3T3).

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Spiral (helical) computerized tomography (CT) scan

Chest spiral CT scan with radiocontrast agent showing multiple filling defects both at the bifurcation and in the pulmonary arteries

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Ventilation and Perfusion Lung scan: Test is used to identify areas of the lung not receiving air flow or blood flow. Ventilation without perfusion suggests the probability of a pulmonary embolus .Two parts to the test: 1)Perfusion scan: Radioisotope IV injection. Scans to detect anything in the pulmonary circulation. 2)Ventilation scan: Inhale radioactive gas (xenon). This displays how the gas within the lungs distributes.

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Normal lung ventilation and poor lung perfusion 21

Pulmonary Angiography: Radio contrast is injected into the pulmonary artery or its branches to detect any vessels fill unsymmetrical and have defect or obstruction.

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Picture shows large, acute embolus in the right lower lobar pulmonary artery (arrowhead).

Venous Ultrasound or ultrasound Doppler: uses highfrequency sound waves to check for blood clots in the thigh veins and a transducer is used to transmit any sound waves found and provides an image on a computer screen. The test is fast and pain-free.

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Classic Wells Criteria to Assess Clinical Likelihood of Pulmonary Embolism:

SCORE POINTS DVT symptoms or signs 3

An alternative diagnosis is less likely

than PE Heart rate >100/min Immobilization or surgery within 4 weeks Prior DVT or PE Hemoptysis Cancer treated within 6 months or metastatic

1.5 1.5

1.5 1 1

Interpretation:4 score points = high probability 24 4 score points= non high probability

Medication and Treatment:

Anti platelet: to prevent platelet aggregation Oral Plavix and oral Aspirin Anticoagulant drugs to prevent existing blood clots from enlarging and additional clots from forming i) Parental: Heparin(targeted to an INR of 2.0 to 2.5 times normal)within 1st 24hrs of treatment. ii)Low Molecular Weight Heparin (LMWH):S/C Arixtra 7.5mg/ml.It does not require the blood test monitoring that is commonly recommended for conventional heparin. iii)Oral: Warfarin (inhibits clotting but takes longer to start working. Used for long term).

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Heparin and warfarin are given together for 5 to 7 days, until blood tests show that the warfarin is effectively preventing clotting. Then, the heparin is discontinued

2. Thrombolytic drugs break up and dissolve blood clots. I) Streptokinase, ii) Alteplase (tPA)
Indication: used for people who appear to be in danger of dying of pulmonary embolism. Contraindication: cannot be given to people who have had surgery in the preceding 2 weeks ,pregnant, have had a recent stroke, or tend to bleed excessively.

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Surgical Therapy
Inferior vena cava filters placed into the inferior vena cava typically beneath the renal vein under fluoroscopic guidance. prevent large clots from travelling to the lungs by mechanically blocking their migration. Indications for patient that has a contraindication to anticoagulants, complications of anticoagulation therapy, or failure to anticoagulant therapy. Vena Cava Filter:

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Picture A showing a postoperative picture of the IVC filter encased in blood clot. Picture B showing an intraoperative picture of the IVC filter in the right pulmonary artery.

Pulmonary embolectomy is a surgery is performed to remove clot. An emergency embolectomy may be indicated for a patient with a severe obstruction who did not respond to the usual therapy.

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Emergency Management:
1.Variable oxygen administration from low flow oxygen by nasal cannula to intubation, depending on patient needs to maintain oxygenation in brain and vital organ. 2.Analgesics may be administer intravenously (IV) if the patient uncomfortable. 3.Iv fluids and vasopressors should be used to maintain pressure 4.Iv anticoagulant are initiated to prevent further clot formation 5.Fibrinolytic therapy should be started immediately in the unstable patient in Emergency Department which diagnosed Pulmonary embolism.

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Summary of Pulmonary Embolism treatment

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Patients Personal Data

Name: Mr.S Aged: 73 years old D.O.B : 22/03/1939 Gender: Male House:Shah Alam Selangor with family Allergies:seafood.

Race: Malay
Religion:Islam Occupation: Retired police in Singapore Diagnosis: Massive Pulmonary Embolism

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Patients Medical Problem

K/C of Pulmonary Embolism in 2009 Treatment in KPJ Selangor: started with s/c Heparin and discharge with tablet Warfarin. Defaulted treatment since 2009 D/M Type 2,HPT,Hypercholestrolemia,IHD, also defaulted treatment Echocardiogram in KPJ: Old MI,RT ventricle dilatation, but no angiogram done there. Taking chinese medicine on and off.

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Patients Medical history:

Day 1 in KPJ Selangor @ 22nd October 2012 C/O: Sob, fever and cough 3/7.Bp: 117/78, pulse 120/minute, oxygen saturation 88% on air. IX WBC Lymphocyte Glucose Total cholesterol Triglycerides LDL cholesterol CKMB 33 Result 19.6mmol/L 18.1mmol/L 18.2mmol/l, 6.8mmol, 2.20mmol/L 4.9mmol/L 47 u/L .

Chest x-ray: cardiomegaly

ECG rhythm: Atrial Flutter Recurrent Pulmonary Embolism. TX: High flow mask Oxygen 10 liter Antiplatelet Tablet Plavix 300mg and Tablet Aspirin 300mg Plan: To admit, patient refuse and wanted to go to UMMC. In UMMC: BP 104/84mmhg, Temperature 36.0 C, Oxygen Saturation 99% on high flow mask 10 liter and respiration rate 30/minute. Wells criteria >4 ECG rhythm was shown Atrial Flutter with pulse rate 142/min 34

ECG rhythm was shown Atrial Flutter with pulse rate 142/min

Indicate PE 35

Investigation done in Trauma and Emergency UMMC

IX Glucose WBC Platelet Result 18.1mmol/L, 17mmol/L 141mmol/L

Creatinin
Trop I D-dimer

169umol/L indicate PE
0.48 ng/ml positive (8001600ng/ml). indicate PE

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ABG result : pH 7.408 PCo2: 28.5 PO2: 70.4 HCo3: 20

Indicate PE

Impression : Respiratory Alkalosis with Fully Compensated with Moderate Hypoxia.

TX: IVI Amiodarone 150mg in 100cc normal saline over 1 hour IVI Rocephine 2gm stat IV Actrapid 8 unit stat IV drip normal saline 2 pint in 24hours. monitor urine output and blood glucose QID Plan:CT pulmonary angiogram(CTPA) IV N-Acetylcysteine(NAC) as pre contrast, Creatinin result was high.The NAC used for patient to prevent kidney damage that can be cause by Iodine containing dyes that used to enhances 37 the quality of CTPA.

The CTPA result was shown Extensive Bilateral Pulmonary Embolism

Plan: IVI Thrombolytic with Streptokinase. IVI Streptokinase 200,000 unit stat and then 50,000 unit over 24 hours IVI Amiodarone for maintenance 600mg over 12 hours as ECG still showing Atrial Flutter with pulse rate132/min. Admit in Coronory Care Unit (CCU).

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ECG still show Atrial Flutter with HR 132/min

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On arrival to CCU: ECG rhythm reverted to sinus rhythm

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Verbally order to stop ivi Amiodarone by Dr Wahab, Cardiologist after inform by staff nurse.

Day 2 in CCU 23rd October 2012 IVI Streptokinase completed. Plan: for warfarinazation, Inferior Vena Cava Filter Ultrasound Doppler lower limb to rule out Deep Vein Thrombosis. Day 3 in CCU 24th October 2012 Started Low Molecular Weight Heparin therapy S/C Arixtra 7.5mg on daily Tablet Warfarin at dosage 10/5/5 mg Ultrasound Doppler result finding was Bilateral Lower Limb DVT.

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Day 4 @ 25 October 2012

Patient was seen by Prof Wan Azman. IVC filter was inserted. The IVC filter was approach at Right Femoral Vein. Patient was stable no other complication during the procedure. Planned to monitor INR daily.

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INR Monitoring Chart from 24/10/ 12 to 29/10/12

Date Thrombosis INR 24/10/12 1.3 Anticoagulant Dosage(mg) Clinical progress And comment Given@1800hrs order by Dr Athar

warfarin

10

25/10/12

2.3

warfarin

Given @1900hrs order by Dr Athar

26/10/12

7.5

warfarin

With hold

Inform Dr Diana Ng@ 2000hrs.To repeat INR cm and watch for bleeding tendencies.

27/10/12

7.4

warfarin

With hold

Inform Dr Diana Ng@0800hrs

28/10/12

6.6

warfarin

With hold

Inform Dr Vijayan

29/10/12

3.0

warfarin

Given@1000hrs order by Dr Diana Ng

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Patient was discharge at Day 8 in 4u, upon discharge patient was stable, patient was given follow up at Cardio Clinic at 5/11/12. INR on arrival on follow up day .Discharge with medication Simvastatin 20mg on night, Metformin 250mg daily, Warfarin 1mg on daily.

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Nursing Diagnosis 1: High risk of cardiac arrest. Objective: Sign and symptom of cardiac arrest detected early. Nursing Intervention 1: 1.Assess and record vital sign closely every 15 to 30 minutes. 2. Assess skin color and temperature. 3. Place patient in cardiac monitor. 4.Administer antiarhythmias drugs as ordered. 5.Prepare resus trolley at patient bay site and make sure all the intubation equipment well function. 6.Reduce environmental stimuli and use a calm reassuring manner. 7.Inform early to the doctor if any abnormal sign. 45

Nursing Diagnosis 2: Impaired gas exchange. Objective: Patient maintain optimal gas exchange

Nursing Intervention 2:
1.Frequently asess respiratory status. 2.Asses mental status patient. 3.Monitor ABG and note the changes. 4.Position patient in high fowlers. 5.Administer oxygen via high flow mask 10-15 liter. 6.Maintain bed rest. 7.Administer medications anticoagulant . 46

Nursing Diagnosis 3: Risk of bleeding. Objective: Sign and symptoms bleeding detected early.
Nursing Intervention 3 1.Assess frequently sign of bleeding. 2.Assess Platelet count and Coagulation test. 3.Try to avoid invasive procedures.

4.Apply direct pressure to injection and venous puncture site.

5.Maintain fluid intake at least 3 liter/day unless contraindicated. 6.Administer stool softer as ordered. 7.Keep Vitamin K available for Warfarin therapy. 8.Caution patient to avoid activities that increased risk of trauma. 47

Nursing Diagnosis 4: Deficient knowledge. Objective : Patient and family verbalizes knowledge. Nursing Interventions 4 1. Assess patients health care literacy. 2.Discuss process of venous thromboembolism and ways to prevent thrombosis and discomfort. 3. Avoiding restrictive clothing and prolonged periods of standing and elevating legs above heart level. 4.Teach signs of venous stasis ulcers and advise patient to seek for treatment

5.Stress importance of avoiding trauma to extremities

and keeping skin clean and dry. 48

6. Discuss prescribed exercise program. 7 .Teach patient how to apply antiembolic hose if prescribed. 8. Describe indicators that necessitate medical attention. 9 . Encourage long term management of venous stasis with elastic stockings. Conclusion: Pulmonary embolism is not a disease but it is complication of the disease.The most important was preventing pulmonary embolism begins with preventing DVT.

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SUMMARY OF PREVENTING DVT and PE

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References: Alan Charters, Mary Dawood, Robert Crouch and Paula Bennet.(2010). Chapter 7, Respiratory Emergencies, Pulmonary Embolism. Oxford Handbook of Emergency Nursing South-East Asian Edition. Gearts.W.O.(2007).Inferior Vena Cava Filters. Retrieved October 23rd ,2012,from The Thrombosis Interest Group of Canada http://www.tigc.org/eguidelines/vena cava04.htm. Hirsch,Hoak.(2009).Management Of Deep Vein Thrombosis And Pulmonary Embolism .Retrieved October 26th,2012, from American Heart Association Journals http://www.circ.ahajournals.org/cgi/content/full/93/12/2212.

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Lorene Newberry.(2003). Sheehys EmergencyNursing Principles And Practice.(5th ed.).Emergency Nurses Association. St Louis, Missouri: Mosby Elsevier. Mayoclinic, S.(2012).Pulmonary EmbolismMayoclinic.com. Retrieved October 28,2012,from http://www.mayoclinic .com. health/pulmonaryembolism/Dsection=prevention. National Heart Lung And Blood Institute.(2011).What Is Pulmonary Embolism? Retrieved October 29, 2012, from http://www.nhlbi.nih.gov/health/health topics.

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Thank you for your attention

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