Pulmonary

Embolism

Introduction
Pulmonary embolism is a
common and often fatal
disease.
Mortality can be reduced
by prompt diagnosis and
therapy.
Clinical presentation of
PE is variable and
nonspecific ,making
accurate diagnosis
difficult.
2/3 of the patient
remained undiagnosed.

Definition

Pulmonary embolism is a
blockage of
the main artery of the lung
or one of its branches by a
substance that has
travelled from elsewhere in
the body through the blood
steam

INCIDENCE
In a study of more than 42
million deaths that occurred
over a 20 year duration .
Almost 600,000 patients
(approximately 1.5 percent)had
been diagnosed with PE.
Estimates of the incidence of PE
have been affected by the
introduction of computed
tomographic pulmonary
angiography(CT-PA)into routine
clinical practice.

Risk Factors
Deep vein thrombosis
Triads of Virchows
Venous stasis
Hyper coagulation status
Endothelial disease
other predisposing
conditions
Advanced age
Obesity
Pregnancy
Oral conraceptive use
History of previous pulmonary
embolism
Constrictive clothing

Pathophysiology
Originate

primarily from Deep

Venous System of lower
extrimities.
Ilio-femoral thrombi and pelvic
viens appear to be the most
clinically recognized sources.
Air,amniotic fluid and fat emboli
are lower causes.

Classification
Classification of
PE
ACUTE
CHR0NIC
Massive

Submassive

Explanation
Patients with acute PE typically
develop signs and symptoms
immediately after obstruction
of pulmonary vessels.
Patients with chronic PE tend to
develop slowly progressive
dyspnea over a period of years
due to pulmonary hypertension.
Massive pe causes
hypotension .defined as systolic
blood pressure <90mmhg or
drop in systolic blood pressure
of >40 mmHg from baseline for
a period >15 minutes.

All acute PE not meeting the

definition of massive PE are
considered submassive PE.

Signs &
Symptoms
Symptoms
Dyspnea
Chest pain
Cough
Hemoptysis
Diaphoresis
Anxiety

Signs
Tachypnea
Tachtcardia
Cyanosis
Collapse
Circulatory
instability
Jugular
venous
distension

Assessment and
Diagnostic
findings
Clinical assessment
for
Pulmonary Embolism

Clinical symptoms of DVT

3
points
3

Other diagnosis less likely

than PE
Heart rate >100

1.5

Immobilization (>3 days)or

surgery in the previous 4
weeks

1.5

Previous DVT/PE

1.5

Hemoptysis

Malignancy

1
Probability

Score

(Wells criteria)
High

>6

Moderate

2 to 6

low

<2
Simplified clinical
probability

Diagnostic
Findings
Chest Radiography
Atelectasis or a pulmonary
parenchymal abnormality .
Pleural effusion.
12% of the chest radiographs in
patients with PE were
interpreted as normal.

Elctrocardiography.
Sinus tachycardia.
Right bundle branch block.
Precordial T-wave inversion and
ST segment changes.
Arterial Blood Gas
ABGs usually reveal hypoxxemia
,hypocapnia and respirayory
alkalosis.

Echocardiography
Only 30 to 40 percent of patients
with PE have echocardiographic
abnormalities.
Increased right ventricular size.
Decreased RV function.
Tricuspid regurgitation.

Ventilation
Perfusion(V/Q)Scan
Diagnostic accuracy was greatest when
the V/Q
scan
was combined with clinical
probability
which was determined by the clinician
prior
to the V/Q scan.
Patients with high clinical probability
of PE and a high probability v/q scan
had a 95% likelihood of having PE.
Patients with low clinical probability of
PE and a low probability v/q scan had
only a 4% likelihood of having PE.

normal V/Q scan exclude PE.

lower extremity doppler
Lower extremity venous
ultrasound is sometimes
performed during the diagnostic
evaluation of PE.The rationale
is that venous thrombosis
detected by ultrasound.

Pulmonary Angiography
Pulmonary angiography is a
procedure that uses a special
die {contrast material} and
xray to see how blood flows
through the lungs.
Procedure
It is performed by a injecting
contrast into a pulmonary artery
branch after percutaneous
catheterization,usually via the
femoral vein.A filling defect or
abrupt cutoff of a small vessel
is indicative of an embolus.

Risk
Allergic reaction to contrast.
Damage to the blood vessels as
the needle and catheter are
inserted.
Excessive bleeding or blood
clots.
Heart attack or strock.
Injury to nerve.
Kidney damage from contrast.

CT Pulmonary
Angiography(CT-PA)
Spiral CT scannig with
intravenous contrast is a
commonly used diagnostic
modality for a patients with
suspected PE.
One of the most commonly
cited benefits of CT-PA is its
ability to detect alternative
pulmonary abnormality .

Advantages and
Disadvantages
Specificity
Availabity
Safety
Relative
rapidity of
procedure
Diagnosis of
other disease
entities.
Advancing
technology

Expense
Not portable
Poor
visualization
of certain
regions.
Reader
expertise
required

Treatment
AIM
Prevent death and morbidity
Reduse the incidence of
recurrence
Primary Treatment
Supplemental oxygen for
hypoxemia if the PE is small
Intravenous infusion lines
Hypotension treated by
ionotropes
Continuous ECG monitoring

Anticoagulation Therapy
Introduction
Anticoagulation is the main
therapy for acute PE.Its goal is
to decrease mortality by
preventing reccurent PE.
Initiation of Anticoagulant
Parenteral anticoagulant therapy
should be initiated in all patients
in whom acute PE has been
confirmed.
The efficiency of parenteral
anticoagulant therapy depends
upon achieving a therapeutic
level of anticoagulation with in
the 24 hours of treatment.

Options include
low molecular weight heparin
Intravenous unfractionated
heparin
Subcutaneous unfractionated
heparin

Low molecular weight heparin

recommend for
most haemodynamically
patients with PE
rather than IV UFH,S/C UFH
Dosing
formulation
Enoxaparin
Tinzaparin
Dalteparin
Nadroparin
Reviparin

Unfractionated
Heparin
Indication
a. Persistent hypotension due to
PE
b. Increased risk of bleeding
c. Thrombolysis is being
considered
d. Concern about subcutaneous
absorption

Dosing
IV UFH
o Several protocols for the
administration of IVUFH.
o All of the protocols administer
the IVUFH by continuous
infusion .
o Weight based dosing protocol is
our clinical practice.
o Administering starting bolus of
80u/kg/hr

S/S UFH
SC UFH can be initiated with
intravenous bolus of 5000u.
Warfarin

The majority of oral

anticoagulants are vit.k
Antagonists,which supress
production of vit.k dependent
clotting factor.
Warfarin is the most common
and best vit.k antagonist.

Initiation
Warfarin can be initiated on the
same day or after heparin is
begun.
Warfarin should be overlapped
with heparin for minimum of
five days and until the INR has
been with in the theraprutic
range.
Dosing
Administering warfarin using an
initial dose of not more than
5mg per day for first two days.

SUMMARY
For haemodynamically stable
patients with confirmed or
suspected PE recommended ,
initial treatment with lmwh.
For patients with confirmed or
suspected PE ,severe renal failure
suggests UFH
For patients with confirmed or
suspected PE who have persistent
hypotension ,increased risk of
bleeding ,potential abnormal
subcutaneous absoption ,or whom
thrombolysis may be performed
suggest IV UFH

Warfarin therapy initiated at the

same time or after lmwh,ufh.
Recommended that warfarin
dose be adjusted to achieve an
INR of 2.5.

Thrombolytic Therapy
Thrombolytic therapy also may
be used in treating PE.
options
Steptokinase
Urokinase
Alteplase
Anistreplase
Merits
Resolves the thrombi or emboli
more quickely and restore more
normal hemodynamic
functioning of pulmonary
circulation

Redusing pulmonary
hypertension
improving perfusion
,oxygenation,and cardiac out
put.
Contraindication
CVA with in past 2 months
Active bleeding
Surgery with in 10 days of the
thromtic event
Recent labour and delivery
Trauma

IVC Filters

Inferior vena cava filters provide

a screen in the inferior vena
cava ,allowing blood to pass
through while large emboli
from the pelvis and lower
extrimities are blocked and
fragmented befpre reaching the
lung.

Surgical
Management
Embolectomy
a) Catheter embolectomy
b) Surgical embolectomy
Catheter
Embolectomy
c) Rheolytic embolectomy
Using a rheolytic embolectomy
catheter,embolectomy
accomplished by injecting
pressurized saline through the
catheters distal tip, which
macerates the emboli.

Suction embolectomy
Suction embolectomy involves
suctioning thrombus through a
large lumen catheter by
manually applying negative
pressurewith an aspiration
syringe.
Thrombus fragmentation
Mechanical disruption of the
thrombus can be achieved by
manually rotating pigtail
catheter

Surgical thrombolectomy
A surgical thrombolectomy is
rarely performed, patients with
massive PE.

Care of Patient
with PE

Minimizing The Risk of Pulmonary

Embolism
A major responsibility of the nurse is to
identify patients at high risk for PE and to
minimize the risk of PE in all patients.
Therefore, the nurse must give attention to
conditions predisposing to a slowing of venous
return (i.e. prolonged immobilization,
prolonged periods of sitting/traveling, varicose
veins, spinal cord injury), hypercoagulability
due to release of tissue thromboplastin after
injury/surgery (i.e. pancreatic, GI, GU, breast,
or lung tumor, increased platelet count in
polycythemia), venous endothelial disease (i.e.
thrombophlebitis, foreign bodies such as
IV/central venous catheters)

 Preventing

Thrombus Formation.

The nurse:
encourages ambulation and active and passive
leg exercises to prevent venous stasis in
patients on bed rest and to help increase venous
flow.
discourages the patient against sitting or lying
in bed for prolonged periods, crossing the legs,
and wearing constricting clothing. Legs
discourages legs dangling or feet placed in a
dependent position while sitting on the edge of
the bed; instead, the patients feet should rest
on a chair.
Should not leave intravenous catheters in place
for prolonged periods.

 Assessing Potential For

Pulmonary Embolism. The nurse
should:
examine patients who are at risk for
developing PE for a positive Homans sign
(pain in the calf as the foot is sharply
dorsiflexed), which may or may not indicate
impending thrombosis of the leg veins. A
positive Homans sign may indicate DVT.

 Monitoring

Thrombolytic Therapy.

The nurse:
keeps the patient on bed rest
assesses vital signs Q2H.
ensures that tests to determine prothrombin time or
partial thromboplastin time are performed 3 to 4
hours after the thrombolytic infusion is started to
confirm that the fibrinolytic systems have been
activated.
ensures that only essential venipunctures are
performed because of the prolonged clotting time,
and manual pressure is applied to any puncture site
for at least 30 minutes.
uses pulse oximetry to monitor changes in
oxygenation.
immediately discontinues the infusion if
uncontrolled bleeding occurs.

 Managing

Chest Pain. The

nurse:
Places the patient in a semi-Fowlers position
which is more comfortable for breathing.
continues to turn the patient frequently and
repositioning him to improve the ventilation
perfusion ratio in the lung.
Administers opioid analgesics as prescribed for
pain.

 Managing

Oxygen Therapy.

The nurse:
gives careful attention the proper use of oxygen
and ensures that the patient understands the
need for continuous oxygen therapy.
assesses the patient frequently for signs of
hypoxemia and monitors the pulse oximetry
values to evaluate the effectiveness of the
oxygen therapy.
encourages deep breathing and performs
incentive spirometry to minimize or prevent
atelectasis and improve ventilation.

 Managing

Anxiety. The

nurse:
encourages the stabilized patient to talk about
any fears or concerns related to this frightening
episode.
answers the patients and familys questions
concisely and accurately.
explains the therapy, and describes how to
recognize untoward effects early.